Urinary tract infection (UTI) - suspected in children

Definitions

UTI is best defined as the presence of a significant level of bacteria in the urinary tract in the presence of an inflammatory response. Clinically, UTIs can be grouped into:

• Cystitis (lower tract infection) –usually apyrexial with no systemic symptoms
• Pyelonephritis (upper tract infection) – presents with fever, vomiting, loin pain & rigors

Atypical UTI is characterised by:

• Seriously ill
• Poor urine flow
• Abdominal or bladder mass
• Raised creatinine
• Septicaemia
• Failure to respond to antibiotic treatment within 48 hours
• Infection with non-Escherichia coli organism

Recurrent UTI is characterised by:

• 2 or more episodes of upper tract UTI
• 1 episode of upper tract UTI plus 1 or more episode of lower tract UTI
• 3 or more episodes of lower tract UTI

History and Examination

• Signs and Symptoms of UTI (see table 1)
• Cystitis (lower tract) or pyelonephritis (upper tract) infection? (seedefinitions above)
• Red flags - signs suggesting 'high risk of serious illness' (see red flags)
• Any features of atypical UTI (see definitions above)
• Blood pressure (hypertension increases chance of underlying renal disease)
• Associated constipation
• Voiding pattern – dysfunctional voiding is major risk factor for UTI
• Growth - see RCPCH growth chart

Signs and Symptoms of UTI

Notes

1. UTI may present in infants younger than age 3 months with non-specific symptoms
2. Fever is the most common presentation of UTI in children under 1 year old

Differential Diagnoses

Other common sources of fever in children including serious bacterial or viral infections

Symptoms and signs consistent with a high risk of serious illness

Adapted from NICE fever in children guidelines

Colour

• Pale
• Mottled
• Blue
• Ashen

Activity

• Unable to rouse or does not stay awake once roused
• Weak
• High-pitched or continuous cry
• Appearing ill to a healthcare professional

Respiratory

• Respiratory distress
  • Recession
  • Tachypnoea or
  • Grunting

Circulation

• Reduced skin turgor
• Dry mucous membranes

Other

• Bile stained vomit
• Bulging fontanelle
• Convulsions (febrile or otherwise)
• Abdominal mass

Collect urine sample for dipstick analysis if:

• Unexplained fever greater than 38°C, in any age child, within 24 hours of onset
• Symptoms/signs suggesting UTI (above)
• Feverish illness due to apparent other cause, but not improving

Collect by:

• 'Clean catch' recommended and best practice
• If 'clean catch' not possible, use special collection pads
• Bag specimens strongly discouraged (high incidence of contamination)
• If neither possible then urine should be obtained by catheterisation (CSU), or supra-pubic aspiration (SPA), ideally under ultrasound guidance, in hospital.
• If child very unwell (see 'high risk of serious illness'), do not delay antibiotic treatment while awaiting urine specimen.

Predictive value of dipstick (infants and children less than 3 years)

Notes

1. Dipstick testing unreliable for children younger than 3 years old (frequent passage of urine doesn't allow time for nitrite formation)
2. Use clinical criteria for decision-making in cases where urine dipstick testing does not support clinical findings

Indications for sending sample for MC&S:

• Suspected pyelonephritis (upper tract infection)
• Patient with red flag symptoms
• All cases in children younger than 3 years where UTI is suspected even if the dipstick is negative for leucocytes and nitrites as dipstick is unreliable in this age group
• Nitrite and/or Leukocyte esterase positive
• Recurrent UTIs
• Suspected UTI unresponsive to treatment after 24 - 48 hours
• Clinical symptoms strongly suggest UTI but dipstick test doesn't correlate

Do

Prevent further UTIs by

• Treating constipation
• Advising increased fluid intake
• Discouraging delayed bladder voiding

Don't

• Treat asymptomatic bacteriuria
• Commence antibiotic prophylaxis after single UTI (consider if recurrent)

For treatment choices please refer to North and East Devon Formulary:
Joint Formulary - Chapter 5 - Urinary Tract Infections

Referral Criteria

Acute referral to paediatric specialist (who will follow up and imaging)

• All infants younger than 3 months with suspected UTI
• Aged greater than 3 months with any 'red flags' or atypical features

Referral for imaging and general paediatric outpatient review

3-6 months

• Ultrasound kidneys and bladder within 6 weeks of infection
• Refer to general paediatrics if abnormal ultrasound

6 months – 3 years

• Responds well to treatment within 48 hours
  • No investigation or follow-up
• Recurrent UTI
  • Ultrasound kidneys and bladder within 6 weeks of infection
  • Consider general paediatrics referral

Greater than 3 years

• Responds well to treatment within 48 hours
  • No investigation or follow-up
• Recurrent UTI
  • U/S within 6 weeks specifically requesting 'assessment of bladder emptying'
  • Consider general paediatrics referral

Referral Instructions

e-Referral Service details:

• Specialty: Child & Adolescent Services
• Clinic Type: Other Medical
• Service: DRSS-Eastern-Paediatrics- Devon CCG-15N

Referral Forms

DRSS Referral forms

Patient Information

Info KID – UTI

Info KID - Urinary tests>

Evidence

NICE UTI in Children

NICE Feverish Illness in Children younger than 5

Pathway Group

This guideline has been signed off by the Eastern Locality on behalf of NHS Devon CCG.

Publication date: December 2016