UTI

When to refer:

Admit if:

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 recurrent 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.

Acute Management:

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.

DO:

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.

DON’T:

Treat asymptomatic bacteriuria with antibiotics (usually found on re-checking of a urine sample post UTI).
Commence antibiotic prophylaxis after first-time UTI (but do consider after recurrent UTI).

When to arrange an USS:

1. If < 6 months old with first-time simple UTI that responds to treatment(ultrasound should be carried out within 6 weeks of the UTI)

2. If atypical UTI

seriously ill (for more information refer to the NICE guideline on fever in under 5s
poor urine flow
abdominal or bladder mass
raised creatinine
septicaemia
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.

3. If recurrent 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 recurrent UTI.

References
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.

Date: June 2021

Review Date: June 2022

GP Sifter: Dr S Burns

Contributors: Dr Chris Williams, Consultant Paediatrician, RCHT

Version No. 2.1