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Urinary tract infection in under 16s: diagnosis and management

Diagnosis

Symptoms and signs

  • Infants and children presenting with unexplained fever of 38°C or higher should have a urine sample tested within 24 hours
  • Infants and children with an alternative site of infection should not have a urine sample tested. When infants and children with an alternative site of infection remain unwell, urine testing should be considered after 24 hours at the latest
  • Infants and children with symptoms and signs suggestive of urinary tract infection (UTI) should have a urine sample tested for infection. Table 1 is a guide to the symptoms and signs that infants and children present with

Table 1 Presenting symptoms and signs in infants and children with UTI

Age group Symptoms and signs 
Most common —————————> Least common   
Infants younger than 3 months Fever
Vomiting
Lethargy
Irritability
Poor feeding
Failure to thrive 
Abdominal pain
Jaundice 
Haematuria
Offensive urine   
Infants and children, 3 months or older Preverbal Fever Abdominal pain
Loin tenderness
Vomiting
Poor feeding
Lethargy
Irritability
Haematuria
Offensive urine
Failure to thrive
Verbal Frequency
Dysuria

Dysfunctional voiding
Changes to continence
Abdominal pain  
Loin tenderness
Fever   
Malaise   
Vomiting   
Haematuria  
Offensive urine  
Cloudy urine  

Assessment of risk of serious illness

Urine collection

  • A clean catch urine sample is the recommended method for urine collection. If a clean catch urine sample is unobtainable:
    • other non-invasive methods such as urine collection pads should be used. It is important to follow the manufacturer’s instructions when using urine collection pads. Cotton wool balls, gauze and sanitary towels should not be used to collect urine in infants and children.
    • when it is not possible or practical to collect urine by non-invasive methods, catheter samples or suprapubic aspiration (SPA) should be used
    • before SPA is attempted, ultrasound guidance should be used to demonstrate the presence of urine in the bladder
  • In an infant or child with a high risk of serious illness it is highly preferable that a urine sample is obtained; however, treatment should not be delayed if a urine sample is unobtainable

Urine preservation

  • If urine is to be cultured but cannot be cultured within 4 hours of collection, the sample should be refrigerated or preserved with boric acid immediately
  • The manufacturer’s instructions should be followed when boric acid is used to ensure the correct specimen volume to avoid potential toxicity against bacteria in the specimen

Urine testing

  • For all diagnostic tests there will be a small number of false negative results; therefore clinicians should use clinical criteria for their decisions in cases where urine testing does not support the findings
  • Refer all infants under 3 months with a suspected UTI (see table 1) to paediatric specialist care, and
  • Use dipstick testing for infants and children 3 months or older but younger than 3 years with suspected UTI
    • if both leukocyte esterase and nitrite are negative: do not start antibiotic treatment; do not send a urine sample for microscopy and culture unless at least 1 of the criteria in recommendation apply
    • if leukocyte esterase or nitrite, or both are positive: start antibiotic treatment; send a urine sample for culture
  • The urine-testing strategy shown in table 2 is recommended for children aged 3 years or older*
  • Follow the guidance in table 3 on interpreting microscopy results

Table 2 Urine-testing strategies for children 3 years or older

Dipstick testing for leukocyte esterase and nitrite is diagnostically as useful as microscopy and culture, and can safely be used.
If both leukocyte esterase and nitrite are positive The child should be regarded as having UTI and antibiotic treatment should be started. If a child has a high or intermediate risk of serious illness and/or a past history of previous UTI, a urine sample should be sent for culture
If leukocyte esterase is negative and nitrite is positive Antibiotic treatment should be started if the urine test was carried out on a fresh sample of urine. A urine sample should be sent for culture. Subsequent management will depend upon the result of urine culture
If leukocyte esterase is positive and nitrite is negative A urine sample should be sent for microscopy and culture. Antibiotic treatment for UTI should not be started unless there is good clinical evidence of UTI (for example, obvious urinary symptoms). Leukocyte esterase may be indicative of an infection outside the urinary tract which may need to be managed differently
If both leukocyte esterase and nitrite are negative The child should not be regarded as having UTI. Antibiotic treatment for UTI should not be started, and a urine sample should not be sent for culture. Other causes of illness should be explored

Table 3 Guidance on the interpretation of microscopy results

Microscopy resultsPyuria positivePyuria negative
Bacteriuria positive The infant or child should be regarded as having UTI The infant or child should be regarded as having UTI
Bacteriuria negative Antibiotic treatment should be started if clinically UTI The infant or child should be regarded as not having UTI

Indication for culture

  • Urine samples should be sent 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

History and examination on confirmed UTI

  • The following risk factors for UTI and serious underlying pathology should be recorded:
    • poor urine flow
    • history suggesting previous UTI or confirmed previous UTI
    • recurrent fever of uncertain origin
    • antenatally diagnosed renal abnormality
    • family history of vesicoureteric reflux (VUR) or renal disease
    • constipation
    • dysfunctional voiding
    • enlarged bladder
    • abdominal mass
    • evidence of spinal lesion
    • poor growth
    • high blood pressure

Clinical differentiation between acute pyelonephritis/upper urinary tract infection and cystitis/lower urinary tract infection

  • Infants and children who have bacteriuria and fever of 38°C or higher should be considered to have acute pyelonephritis/upper urinary tract infection. Infants and children presenting with fever lower than 38°C with loin pain/tenderness and bacteriuria should also be considered to have acute pyelonephritis/upper urinary tract infection. All other infants and children who have bacteriuria but no systemic symptoms or signs should be considered to have cystitis/lower urinary tract infection

Laboratory tests for localising UTI

  • C-reactive protein alone should not be used to differentiate acute pyelonephritis/upper urinary tract infection from cystitis/lower urinary tract infection in infants and children

Acute management

  • Note that the antibiotic requirements for infants and children with conditions that are outside the scope of this guideline (for example, infants and children already known to have significant pre-existing uropathies) have not been addressed and may be different from those given here.
  • Infants and children with a high risk of serious illness should be referred urgently to the care of a paediatric specialist
  • Infants younger than 3 months with a possible UTI should be referred immediately to the care of a paediatric specialist. Treatment should be with parenteral antibiotics in line with the NICE guideline on fever in under 5s
  • For infants and children 3 months or older with acute pyelonephritis/upper urinary tract infection:
    • consider referral to a paediatric specialist
    • treat with oral antibiotics for 7–10 days. The use of an oral antibiotic with low resistance patterns is recommended, for example cephalosporin or co-amoxiclav
    • if oral antibiotics cannot be used, treat with an intravenous (IV) antibiotic agent such as cefotaxime or ceftriaxone for 2–4 days followed by oral antibiotics for a total duration of 10 days
  • For infants and children 3 months or older with cystitis/lower urinary tract infection:
    • treat with oral antibiotics for 3 days. The choice of antibiotics should be directed by locally developed multidisciplinary guidance. Trimethoprim, nitrofurantoin, cephalosporin or amoxicillin may be suitable
    • 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
  • For infants and children who receive aminoglycosides (gentamicin or amikacin), once daily dosing is recommended
  • If parenteral treatment is required and i.v. treatment is not possible, intramuscular treatment should be considered
  • If an infant or child is receiving prophylactic medication and develops an infection, treatment should be with a different antibiotic, not a higher dose of the same antibiotic
  • Asymptomatic bacteriuria in infants and children should not be treated with antibiotics
  • Laboratories should monitor resistance patterns of urinary pathogens and make this information routinely available to prescribers

Prevention of recurrence

  • Dysfunctional elimination syndromes and constipation should be addressed in infants and children who have had a UTI
  • Children who have had a UTI should be encouraged to drink an adequate amount
  • Children who have had a UTI should have ready access to clean toilets when required and should not be expected to delay voiding

Antibiotic prophylaxis

  • Antibiotic prophylaxis should not be routinely recommended in infants and children following first-time UTI
  • Antibiotic prophylaxis may be considered in infants and children with recurrent UTI
  • Asymptomatic bacteriuria in infants and children should not be treated with prophylactic antibiotics

Definitions of atypical and recurrent UTI

  • Atypical UTI includes:
    • 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
  • 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

Follow-up

  • Infants and children who do not undergo imaging investigations should not routinely be followed up
  • The way in which the results of imaging will be communicated should be agreed with the parents or carers or the young person as appropriate
  • When results are normal, a follow-up outpatient appointment is not routinely required. Parents or carers should be informed of the results of all the investigations in writing
  • Infants and children who have recurrent UTI or abnormal imaging results should be assessed by a paediatric specialist
  • Assessment of infants and children with renal parenchymal defects should include height, weight, blood pressure and routine testing for proteinuria
  • Infants and children with a minor, unilateral renal parenchymal defect do not need long-term follow-up unless they have recurrent UTI or family history or lifestyle risk factors for hypertension
  • Infants and children who have bilateral renal abnormalities, impaired kidney function, raised blood pressure and/or proteinuria should receive monitoring and appropriate management by a paediatric nephrologist to slow the progression of chronic kidney disease
  • Infants and children who are asymptomatic following an episode of UTI should not routinely have their urine re-tested for infection
  • Asymptomatic bacteriuria is not an indication for follow-up

Information and advice for children, young people and parents or carers

  • Healthcare professionals should ensure that when a child or young person has been identified as having a suspected UTI, they and their parents or carers as appropriate are given information about the need for treatment, the importance of completing any course of treatment and advice about prevention and possible long-term management
  • Healthcare professionals should ensure that children and young people, and their parents or carers as appropriate, are aware of the possibility of a UTI recurring and understand the need for vigilance and to seek prompt treatment from a healthcare professional for any suspected reinfection
  • Healthcare professionals should offer children and young people and/or their parents or carers appropriate advice and information on:
    • prompt recognition of symptoms
    • urine collection, storage and testing
    • appropriate treatment options
    • prevention
    • the nature of and reason for any urinary tract investigation
    • prognosis
    • reasons and arrangements for long-term management if required

Terms used in this guideline

Bacteriuria
Bacteria in the urine with or without urinary tract infection.

Pyuria
White cells in the urine.

 

* Assess the risk of serious illness in line with the NICE guideline on fever in under 5s to ensure appropriate urine tests and interpretation, both of which depend on the child’s age and risk of serious illness.

© NICE 2017. Urinary tract infection in under 16s: diagnosis and management. Available from: www.nice.org.uk/guidance/CG54. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. 

First included: October 2007, updated October 2017.