Urinary tract infection (UTI) - suspected

Scope

  • Diagnosis and primary management of urinary tract infection (UTI) in children less than 16 years

Out of scope

  • Children with established pathology of the renal tract
  • Children with immune deficiency including those on immunosuppressive drugs
  • Long-term management of repeated UTIs in sexually active girls

Assessment

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? (see definitions 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
Age Most common Less common Least common
Less than 3 months Unexplained fever
Vomiting
Lethargy
Irritability
Poor feeding
Faltering growth
Abdominal pain
Jaundice
Haematuria
Offensive urine
Preverbal (infants & toddlers) Fever Abdominal pain
Loin tenderness
Vomiting
Poor feeding
Lethargy
Irritability
Haematuria
Offensive urine
Faltering growth
Verbal (older children) Frequency
Dysuria
Dysfunctional voiding
Deterioration in continence
Abdominal pain
Loin tenderness
Fever
Malaise
Vomiting
Haematuria
Offensive/cloudy urine

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

Red Flags

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

Investigations

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)
Dipstick Nitrate positive Nitrite negative
Leukocyte esterase
positive
Likely UTI, send for MC&S,
start treatment
Treat if UTI clinically likely,
but may indicate infection
elsewhere
Leukocyte esterase
negative
Suspect UTI if freshly
voided sample, send for
MC&S, start treatment

UTI unlikely

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

Management

Infection Antibiotics
BNFc for dose
Course length Comments
Younger than 3 months Refer acutely to general paediatrics
Older than 3 months
Upper tract UTI
Oral Co-Amoxiclav 7-10 days. Assess response
after 24-48 hours. Check
culture result in
non-responders
Consider referral to
general paediatrics
for intravenous
treatment if severely
unwell/not
tolerating oral


Older than 3 months
Lower tract UTI
Oral Trimethoprim
Alternatives are
Nitrofurantoin or
Co-Amoxiclav
3 days. Assess response
after 24-48 hours. Check
culture result in non-responders
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

Referral Criteria

Pre-choice Triage is currently active for this specialty.

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-Northern-Children's & Adolescent Services-NEW Devon CCG - 99P

Referral Forms

DRSS referral form

Supporting Information

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 Northern Locality on behalf of NEW Devon CCG.

Publication date: February 2017

Review date: January 2019

 

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