When to refer:
- Infants and children with a high risk of serious illness (ie pyelonephritis)
- Infants younger than 3 months with a possible UTI
Otherwise refer if:
- Any child with an abnormal USS
- Any child with atypical UTI
- Any child with recurrant UTI
When to suspect a UTI:
Any child under the age of 6 months with a fever should have a urine test as should any infant or child with a fever without an obvious focus.
Urine testing for children > 3/12 of age:
A clean catch sample is the recommended method, if not possible use special collection pads. Do not use cotton wool balls, gauze, sanitary towels or urine bags.
When to send for culture:
- in infants and children who are suspected to have acute pyelonephritis/upper urinary tract infection
- in infants and children with a high to intermediate risk of serious illness
- in infants under 3 months
- in infants and children with a positive result for leukocyte esterase or nitrite
- in infants and children with recurrent UTI
- in infants and children with an infection that does not respond to treatment within 24–48 hours, if no sample has already been sent
- when clinical symptoms and dipstick tests do not correlate.
Admit infants < 3 months of age with a possible UTI and all infants and children with
a high risk of serious illness.
NOTE Nitrofurantoin liquid is very expensive and should only be used where there is no suitable alternative. Please discuss with microbiologist and/ or pharmacist.
- The parents or carers should be advised to bring the infant or child for reassessment if the infant or child is still unwell after 24–48 hours. If an alternative diagnosis is not made, a urine sample should be sent for culture to identify the presence of bacteria and determine antibiotic sensitivity if urine culture has not already been carried out.
- Check urine sensitivities and change antibiotics as appropriate.
- If an infant or child is receiving prophylactic medication and develops an infection treat with a different antibiotic.
- Treat constipation.
- Advise to increase fluid intake.
- Discourage delayed voiding.
- Treat asymptomatic bacteriuria with antibiotics (usually found on re-checking of a urine sample post UTI).
- Commence antibiotic prophylaxis after first-time UTI but consider after recurrent UTI.
When to arrange an USS:
- If < 6 months with first-time simple UTI that responds to treatment, ultrasound should be carried out within 6 weeks of the UTI
- If atypical UTI
- seriously ill (for more information refer to the NICE guideline on fever in under 5ss
- poor urine flow
- abdominal or bladder mass
- raised creatinine
- failure to respond to treatment with suitable antibiotics within 48 hours
- infection with non-E. coli organisms
These children may need discussion with the paediatric registrar on-call as admission may be required.
- If recurrant UTI:
- 2 or more episodes of UTI with acute pyelonephritis/upper urinary tract infection, or
- 1 episode of UTI with acute pyelonephritis/upper urinary tract infection plus one or more episode of UTI with cystitis/lower urinary tract infection, or
- 3 or more episodes of UTI with cystitis/lower urinary tract infection
NB - If > 6 months with first-time UTI that responds to treatment, routine ultrasound is not recommended unless the infant or child has atypical UTI or recurrant UTI.
NICE Urinary tract infection in under 16s: diagnosis and management Clinical guideline [CG54]Published date: August 2007 Last updated: September 2017.
Paediatric Antimicrobial Guide, Royal Cornwall Hospital Trust, http://intranet.cornwall.nhs.uk/Intranet/AZServices/A/AntimicrobialPrescribing/AntimicrobialGuidance.aspx. July 2018.
Dr Rebecca Harling, RMS GP Paediatric Lead, July 2018.
Dr Chris Williams, Consultant Paediatrician, Royal Cornwall Hospital, July 2018.