MANAGEMENT OF FIRST PRESENTATION OF
URINARY TRACT INFECTION IN CHILDREN
Scope of Guideline
The management of any child presenting with a first urinary tract infection (UTI) to their GP,
the emergency department or the paediatric team. These guidelines are based on the NICE
Clinical Guideline 54, Urinary Tract Infection in Children.
Indications for checking a urine sample
• urinary symptoms eg. frequency, dysuria, enuresis, haematuria
• upper renal tract symptoms eg. loin pain, fever
• any child who presents with fever without an obvious cause (PUO) or sepsis/collapse
• babies and toddlers with non-specific symptoms eg. lethargy, irritability, poor feeding,
vomiting
History and Examination
A thorough history and examination should be taken. Particular points that suggest serious
underlying pathology include:
• poor urine flow
• history suggestive of previous UTIs or previous confirmed UTIs
• recurrent fever of uncertain origin
• antenatally diagnosed renal abnormality
• family history of vesico-ureteric reflux (VUR) or renal disease
• constipation
• dysfunctional voiding
• enlarged bladder
• abdominal mass
• evidence of spinal lesion
• poor growth
• high blood pressure
Nursing intervention
On admission, assess child’s general condition. If child is clinically very unwell, ensure doctor
is called immediately.
Check and record:
- temperature
- heart rate
- respiratory rate
- blood pressure (if distressed, ensure this is undertaken before child is discharged or
transferred to ward)
Consider need to undertake regular observations and blood pressure measurements and discuss
frequency with medical staff.
Discuss with parents and assess and score child’s level of discomfort and pain. Ensure
analgesia is prescribed and monitor effects.
Obtain urine sample and dipstick immediately. In non-toilet trained children inform parents of
method for clean catch technique, ensure nappy area is cleaned with soap and water and dried
well. Give parents an information leaflet and provide them with all the equipment needed.
See criteria below for sending urine specimens to the lab.
Dr I Norton
March 2009 1 Review Date March 2011
Diagnosis
Clean catch urine is recommended. If urgent antibiotic treatment is required in infants, a supra-
pubic aspirate or catheter specimen will need to be taken. Otherwise, it may be necessary to
collect urine using a pad. Pad urine samples are often contaminated, however, so should be
avoided if possible, or two separate samples obtained before starting antibiotics.
Urine Testing
Urine sample should be tested on the ward using dipsticks that detect leucocytes, nitrites,
protein and blood. If there is high clinical suspicion of UTI, or there are nitrites and/or
leucocytes on dipstick, the sample should be sent to the microbiology lab for microscopy and
culture. The urine dipstick result will help guide treatment, especially in children over 3 years
of age (refer to chart on page 4).
UTI is confirmed if there is an increase in white cells (WCC >200 /µl on microscopy) with
pure growth of an organism >105 /ml on culture. A low or insignificant increase in WCC with a
low growth of organisms or mixed growth of several organisms suggests contamination. Such
tests should be repeated, preferably before starting antibiotics. A child with symptoms of a UTI
with either WCC >200 or significant growth of bacteria should be treated as having a UTI.
Once a UTI has been treated, asymptomatic infants and children do not need routine re-testing
of urine for infection.
Antibiotic Treatment
Most simple UTIs will be successfully treated with a short course of oral antibiotics.
All babies less than 3 months must be started on intravenous antibiotics.
Consider intravenous antibiotics in the following situations:
• systemically well babies less than 6 months of age
• children with systemic upset eg. fever, vomiting, poor feeding
• upper UTI (ie. loin pain, fever)
• inability to tolerate oral fluids
Oral antibiotics: trimethoprim, nitrofurantoin or cefalexin
Intravenous antibiotics: cefuroxime, cefotaxime/ceftriaxone if septicaemic
The antibiotic may need to be changed once organism sensitivities are known.
A treatment course of oral antibiotics should be given for 5-7 days. The duration of intravenous
antibiotics depends on the clinical response to treatment.
Reassessment will be required if the infant or child remains unwell or if the fever does not
settle after 48hrs. If an alternative diagnosis is not made, take another urine sample and
consider changing to a different antibiotic treatment.
Antibiotic Prophylaxis
This should be given to infants less than 1 year of age whilst awaiting investigations and to
infants with an antenatal diagnosis of renal pelvis dilatation (see postnatal ward guidelines).
Prophylaxis should be considered in children with recurrent UTIs or in those with underlying
renal abnormalities. The antibiotic used may depend on previous microbiology results.
Antibiotic Dosage
Treatment: Trimethoprim 4mg/kg twice daily
Cefalexin 12.5mg/kg twice daily
Cefuroxime 20mg/kg three times daily iv.
Cefotaxime 50mg/kg three times daily iv.
Dr I Norton
March 2009 2 Review Date March 2011
Prophylaxis: Trimethoprim 2mg/kg at night
Cefalexin 12.5mg/kg at night
Imaging
Ultrasound during acute infection: children who are systemically unwell
consider in children with an atypical UTI
Ultrasound as outpatient: children under 1 year
(if not performed acutely) children over 1 year with atypical or recurrent UTIs
MCUG children under 1 year with atypical or recurrent UTIs
DMSA (4-6 months after UTI) children under 3 years with atypical or recurrent UTIs
children over 3 years with recurrent UTIs
Note that when an MCUG is being performed in a child not taking prophylactic antibiotics, oral
trimethoprim should be given for 3 days, with the MCUG taking place on the second day. This
should be prescribed by the doctor ordering the investigation.
Consider MCUG in children over 1 year of age with non-E.coli UTI, family history of VUR,
poor urine flow or dilatation >10mm on ultrasound. It may be beneficial to perform indirect
MAG3 instead, however, so discuss with Consultant Paediatrician or Radiologist first.
Atypical and Recurrent Infections
Refer to the flow chart (page 3) for the definition of an atypical UTI.
Recurrent UTI is defined as:
- two or more episodes of acute pyelonephritis/upper UTI
- one episode of pyelonephritis/upper UTI plus one or more episodes of cystitis/lower UTI
- three or more episodes of cystitis/lower UTI
Follow-up
Infants and children who do not require imaging do not need follow-up.
Those who only require an outpatient ultrasound may not need to be followed up as the
Paediatric Consultant in charge of their care will write to parents with the ultrasound result. If
the ultrasound is found to be abnormal, the Paediatric Consultant will organise any further
imaging and follow-up that is needed.
Infants and children undergoing MCUG and/or DMSA scan will need outpatient follow-up and
the timing of this should be discussed with the Paediatric Consultant.
Parents should be informed of the way in which results will be communicated to them and the
plan for any follow-up. It is also important that, if children are being sent home, parents are
aware of the signs that indicate the antibiotic treatment is not effective and how to access
further medical help. It is often useful to give Open Access to Paddington Ward, especially for
young children in whom urine collection can be tricky, and over weekends.
References
NICE. Urinary Tract Infection in Children. Guidance CG054. 2007
Birmingham Children’s Hospital UTI Guidelines. 2008
These guidelines were produced by Northampton General Hospital Paediatric Department in
consultation with the Departments of Radiology, Pharmacy and Microbiology.
Dr I Norton
March 2009 3 Review Date March 2011
MANAGEMENT OF URINARY TRACT INFECTIONS
refer to paeds: urine microscopy and culture (M, C + S)
AGE 3yrs send M, C + S
nitrite - leucocyte + antibiotics only if clinically UTI
nitrite - leucocyte - explore other causes of illness
Indications to send urine for culture: • acute pyelonephritis/upper urinary tract infection (loin pain, fever
• a high to intermediate risk of serious illness
• younger than 3 years
• a single positive result for leucocyte esterase or nitrite
• recurrent UTIs
Dr I Norton • an infection that does not respond to treatment within 24-48 hours
March 2009 4 • Review Date March 2011 dipstick tests do not correlate
when clinical symptoms and
IMAGING FOR URINARY TRACT INFECTIONS
USS
AGE 3yrs DMSA if recurrent
Definition of atypical: • seriously ill (Appendix 1)
• poor urine flow
• abdominal or bladder mass
• raised creatinine
• septicaemia
• failure to respond to treatment within 48hrs
• infection with non-E.coli organisms
Dr I Norton
March 2009 5 Review Date March 2011
Appendix 1
Traffic light system for identifying risk of serious illness
Green – low risk Amber – intermediate risk Red – high risk
Colour Normal colour of skin, Pallor reported by Pale/mottled/ashen/blue
lips and tongue parent/carer
Activity Responds normally to Not responding normally to No response to social cues
social cues social cues Appears ill to a healthcare
Content/smiles Wakes only with prolonged professional
Stays awake or stimulation Unable to rouse or if roused
awakens quickly Decreased activity does not stay awake
Strong normal cry/not No smile Weak, high-pitched or
crying continuous cry
Respiratory Nasal flaring Grunting
Tachypnoea: Tachypnoea:
RR > 50 breaths/minute RR > 60 breaths/minute
age 6–12 months Moderate or severe chest
RR > 40 breaths /minute indrawing
age > 12 months
Oxygen saturation ≤ 95%
in air
Crackles
Hydration Normal skin and eyes Dry mucous membrane Reduced skin turgor
Moist mucous Poor feeding in infants
membranes CRT ≥ 3 seconds
Reduced urine output
Other None of the amber or Fever for ≥ 5 days Age 0–3 months,
red symptoms or temperature ≥ 38°C
signs Age 3–6 months,
temperature ≥ 39°C
Swelling of a limb or joint Non-blanching rash
Non-weight bearing/not Bulging fontanelle
using an extremity Neck stiffness
Status epilepticus
Focal neurological signs
Focal seizures
A new lump > 2 cm Bile-stained vomiting
CRT = capillary refill time
RR = respiratory rate.
Extract from NICE Guideline 47, May 2007
Dr I Norton
March 2009 6 Review Date March 2011