Paediatric Clinical Guideline
Emergency: 1.1 Cardiopulmonary Resuscitation
Short Title:
Urinary Tract Infection
Full Title:
Date of production/Last revision:
Guideline for the management and investigation of urinary tract infection in
children and young people
June 2008
Explicit definition of patient group
to which it applies:
This guideline applies to all children and young people under the age of 19
years.
Name of contact author
Dr Andy Lunn, Paediatric SpR
Dr Farida Hussain, Consultant Paediatrician
Ext:
January 2011
Revision Date
This guideline has been registered with the Trust. However, clinical guidelines are 'guidelines' only. The interpretation
and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a
senior colleague or expert. Caution is advised when using guidelines after the review date.
Urinary Tract Infection
Background
Recent NICE guidelines on childhood UTI have focussed on early diagnosis and treatment as
the best evidence based prevention strategy for renal damage following UTI. 1 The importance
of looking for a UTI in all febrile children is emphasised. The investigation strategy is then
targeted at high risk groups. These guidelines are in concordance with NICE guidelines with
the exception that locally published research has established that in Nottingham USS by
consultant paediatric radiologists can detect scarring as effectively as DMSA and is therefore
used rather than DMSA in many instances.2,3 This would therefore not be applicable to
centres which have not established this standard in their department.
Definition
UTI is traditionally defined as clinical suspicion plus a growth of 105 organisms/ml (108/L)
of a single bacterium on a CCU/MSU.
 Newer automated microscopy reports issue a bacterial count. This is a sensitive
screening test and bacteria will be seen on all samples therefore the bacterial count
should not be used to diagnose a UTI – see section 4.2;
 Lower growths can indicate a UTI and any growth on a suprapubic aspirate is considered
significant;
 Every urine culture must be interpreted in the clinical context;
 Contaminated urine samples (false positive results) are a problem with bag/pad
specimens
Andy Lunn
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January 2007
Paediatric Clinical Guideline
Emergency: 1.1 Cardiopulmonary Resuscitation
Clinical Assessment
History
Consider UTI in an infant <3 months with:
 Unexplained fever, Vomiting, Lethargy, Irritability
 Poor feeding, Growth faltering
 Abdominal pain, Jaundice, Haematuria, Offensive urine
Consider UTI in a preverbal child older than 3 months with:
 Fever
 Abdominal pain, Loin tenderness, Vomiting, Poor feeding
 Lethargy, Irritability, Haematuria, Offensive urine, Growth faltering
Consider UTI in a verbal child with:
 Frequency, Dysuria
 Dysfunctional voiding, Changes to continence, Abdominal pain, Loin tenderness
 Fever, Malaise, Vomiting, Haematuria, Offensive urine, Cloudy urine
Record the presence or absence of:
 Family history of vesicoureteric reflux or renal disease
 Any antenatal urinary tract abnormality
 History suggestive of, or confirmed, previous UTI
 Recurrent fever of uncertain origin
 Poor urine flow or dysfunctional voiding
 Constipation
Examination
The child should be assessed according to the “Feverish illness in children” (NICE clinical
guidance 47)4
Particular attention should be made to:
 Blood pressure – see guideline on Hypertension
 Abdominal mass or enlarged bladder
 Evidence of spinal lesion and lower limb neurology
 Faecal loading
 Genitalia examination (when appropriate)
 Growth measurements and centiles
Localisation of UTI
A clinical assessment should be made as to the likelihood of:
 Acute pyelonephritis/upper urinary tract infection
o significant bacteriuria (Sec 2) and fever ≥38oC
o or significant bacteriuria (Sec 2) and fever ≤38oC with loin pain/tenderness
 Cystitis
o Significant bacteriuria with absence of systemic features
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Paediatric Clinical Guideline
Emergency: 1.1 Cardiopulmonary Resuscitation
Diagnosis
A urine sample should be dipstick tested whenever a UTI is suspected. In addition, a urine
sample should be sent for culture if:
 Dipstick positive (see below)
 Under 3 years of age
 High to intermediate risk of serious illness (NICE guidelines on feverish illness)
 Recurrent UTI
 Clinical symptoms do not correlate with dipstick
 No response to treatment after 48hrs
Urinalysis
Nitrites and leucocytes on dipsticks are helpful to exclude UTI if both are negative. The
presence or absence of blood or protein has no predictive value in the diagnosis of UTI. The
NICE guidelines recommend their use in those over 3 years of age as below:
 Leucocyte and nitrite positive – treat whilst awaiting culture
 Nitrite only positive – treat whilst awaiting culture
 Leucocyte only positive – treat if clinically good evidence of UTI. Look for other focus
of infection
 Leucocyte and nitrite negative – do not send urine for culture unless high clinical
suspicion of UTI. Look for other focus of infection.
Automated microscopy and urine culture
All samples sent to the laboratory in Nottingham will have an automated microscopy. This will
issue a report on the white cell count, red cell count, bacterial count (all samples will have
some bacteria) and other cells seen (e.g. epithelial cells). If the white cell count and bacterial
count are sufficiently low a negative culture report will be issued immediately and the
sample will not be cultured unless specifically requested on the form or “bladder” specimen of
urine, ie SPA or in/out catheter specimen. The patient can be treated as if they have a
negative culture.
If the white cell count and/or the bacterial count are sufficiently high the sample will be
cultured. Approximately 50% of these samples will have no bacterial growth therefore
decisions on further investigations should be based on the culture result not the automated
bacterial count.
Definitive diagnosis is dependent upon an uncontaminated urine specimen for culture:
 Clean catch urine (CCU) or MSU is sample of choice
 Bag urine – a negative result excludes UTI but a single positive culture does not
prove it and needs repeating
 Suprapubic aspirate (SPA) preferably under ultrasound control or catheter specimen
– safe and reliable but invasive and justified in sick infants <1 year only.
Always ask HOW sample was OBTAINED, record this in the notes and on the request
form. Urine samples should be refrigerated (4oC) if not sent to laboratory immediately.
Andy Lunn
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Paediatric Clinical Guideline
Emergency: 1.1 Cardiopulmonary Resuscitation
Treatment
Treatment should be initiated with empirical therapy as outlined below once an adequate
urine sample has been obtained. The doctor must follow up the result of any urine sent for
culture. The antibiotic therapy should be reviewed once the culture and sensitivity results are
available.
1. If there is a high risk of serious illness (infection screen as clinically indicated and
empirical antibiotics until culture results known (NICE guidelines on feverish illness –
Appendix 1)
2. Less than 3 months of age
 As above. Infection screen as clinically indicated and empirical antibiotics until
culture results known
3. More than 3 months of age with signs of pyelonephritis
 Treat with oral antibiotics for 10 days if sufficiently well5
<1 year old – Cephradine or Co-amoxiclav (Augmentin)
>1 year old – Cephradine or Trimethoprim
 If IV antibiotics required Cefuroxime is the drug of choice. IV antibiotics should
be continued until the pyrexia has settled and culture is available from which an
appropriate oral antibiotic can be given (total duration of treatment 10 days)
4. More than 3 months of age with signs of cystitis
 Treat with oral antibiotics for 3 days if sufficiently well but review if no
improvement after 24-48 hours
<1 year old – Cephradine or Co-amoxiclav (Augmentin)
>1 year old – Cephradine or Trimethoprim
For empirical first line treatment of UTI:
Oral Amoxicillin is not recommended because of a high level of resistant organisms
Oral Trimethoprim is not recommended in <1 year as there is a greater local incidence of
resistant organisms than with cephalosporins
A single dose of IV Gentamicin is only used in severe cases of urosepsis because of risk
of nephrotoxicity/ototoxicity and the need for blood level monitoring. Further dosing may
be considered depending on the clinical condition of the patient, drug levels and
microbiology advice.
These antibiotic guidelines thus differ from those in BNF for Children (2007) but are based on
knowledge of local patterns of antibiotic sensitivities.
5.
Routine prophylaxis whilst awaiting investigations is not routinely recommended but
may be indicated following severe infections or recurrent UTIs while awaiting
investigations.
Andy Lunn
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Paediatric Clinical Guideline
Emergency: 1.1 Cardiopulmonary Resuscitation
Recommended doses of the first line antibiotics
Note: These doses should be adjusted according to estimated GFR if renal impairment noted
from plasma creatinine levels. Refer to BNF for Children (2007) for prescribing details.
Prophylaxis
(mg/kg/dose)
Treatment
Co-amoxiclav
Trimethoprim
Cefuroxime
Cephradine
Nitrofurantoin
Ciprofloxacin
(mg/kg/dose)
Check BNF as depends upon age and
drug concentration
4mg/kg orally 12-hourly
Max dose 200mg
20mg/kg IV 8 hourly
Max dose 750mg
12.5-25mg/kg orally 12-hourly
Max dose 1g
0.75mg/kg orally 6-hourly
Max dose 100mg
Not licensed but refer to BNF
NR
2mg/kg 24-hourly (at night)
Max dose 100mg
NR
3mg/kg 24-hourly (at night)
1mg/kg 24-hourly (at night)
Max dose 100mg
NR
NR = not recommended
Andy Lunn
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Paediatric Clinical Guideline
Emergency: 1.1 Cardiopulmonary Resuscitation
Investigations
Purpose – to target investigations in those most likely to have renal scarring and
malformations predisposing to UTI/pyelonephritis.
The children most at risk of the above are those with severe systemic illness, recurrent
symptomatic UTIs, infants <6/12 of age. The following investigation guideline is based on a
detailed review of the literature, local audit and research on the value of investigation in a
given clinical situation and the NICE UTI guidelines. Investigations are stratified according to
age, atypical features and if recurrent UTI. This investigation guideline is for patients with a
proven UTI. If the diagnosis is uncertain then decisions to investigate should be made on an
individual basis, by a Consultant Paediatrician / Paediatric Nephrologist in discussion with a
Consultant Radiologist and initially limited to the least invasive i.e. USS to exclude major
structural renal abnormalities.
Definitions
Atypical UTI includes:
 Seriously ill and suspected/confirmed septicaemia
 Failure to respond to treatment with suitable antibiotics within 48 hours
 Poor urine flow and/or abdominal or bladder mass
 Raised creatinine
 Infection with non-E.coli organisms
Recurrent UTI:
 2 or more episodes of UTI with acute pyelonephritis/upper urinary tract
infection, or
 one episode of UTI with acute pyelonephritis/upper urinary tract infection plus
one or more episodes of UTI with cystitis/lower urinary tract infection, or
 3 or more episodes of UTI with cystitis/lower urinary tract infection
If it cannot be determined if previous episodes have truly been a UTI or it is unclear
whether they were acute pyelonephritis / upper UTI or cystitis / lower UTI then the
consultant may decide to limit investigations to an USS and only proceed to further
investigations if the USS is abnormal.
Presence of any of these features should be documented in the notes and on any requests
for investigation.
Andy Lunn
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Paediatric Clinical Guideline
Emergency: 1.1 Cardiopulmonary Resuscitation
Imaging Strategies
Children with cystitis/lower urinary tract infection should undergo ultrasound (within 6 weeks)
if they are younger than 6 months or have had recurrent infection. No other investigations are
required for any child with cystitis/lower urinary tract infection unless they have recurrent UTI
and/or abnormality on ultrasound, in which case late DMSA should be considered.
Child less than 6 months of age
Children younger than 6
months
Responds well to treatment within
48hrs without any features for
atypical and/or recurrent UTI
No
Atypical UTI
Recurrent UTI
Ultrasound during the acute
Yesb
Yesb
infection
Ultrasound within 6 weeks
Yesa
No
No
DMSA 4-6 months following
No
Yesc
Yesc
the acute infection
MCUG
No
Yes
Yes
Notes
aIf abnormal consider MCUG
bIn a child with a non-E.coli UTI, responding well to antibiotics and with no other features of
atypical infection, the ultrasound can be requested on a non-urgent basis to take place within
6 weeks
cA detailed ultrasound by an experienced operator can detect renal scarring 3
Child 6 months – 3 years of age
Children 6 months or older
but younger than 3 years
Ultrasound during the acute
infection
Ultrasound within 6 weeks
DMSA 4-6 months following
the acute infection
MCUG
Responds well to treatment within
48hrs without any features for
atypical and/or recurrent UTI
No
Atypical UTI
Recurrent UTI
Yesb
No
No
No
No
Yesc
Yes
Yesc
No
Noa
Noa
Notes
aWhile MCUG should not be performed routinely it should be considered if the following
features are present: dilatation on ultrasound; poor urine flow; non-E.coli infections; family
history of VUR
bIn a child with a non-E.coli UTI, responding well to antibiotics and with no other features of
atypical infection, the ultrasound can be requested on a non-urgent basis to take place within
6 weeks
cA detailed ultrasound by experienced operator can detect renal scarring3
Andy Lunn
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Paediatric Clinical Guideline
Emergency: 1.1 Cardiopulmonary Resuscitation
Children older than 3 years of age
Children 3 years or older
Ultrasound during the acute
infection
Ultrasound within 6 weeks
DMSA 4-6 months following
the acute infection
MCUG
Responds well to treatment within
48hrs without any features for
atypical and/or recurrent UTI
No
Atypical UTI
Yesa,b
No
No
No
No
No
Yesa
Yesc
No
No
Nod
Recurrent UTI
Notes
aUltrasound in toilet-trained children should include repeat scan after bladder emptying if
bladder very full
bIn a child with a non-E.coli UTI, responding well to antibiotics and with no other features of
atypical infection, the ultrasound can be requested on a non-urgent basis to take place within
6 weeks
cA detailed ultrasound by experienced operator can detect renal scarring3
dMAG 3 scan with indirect cystogram may be considered in continent child >4 years if USS
abnormal
Investigations in Siblings
Vesicoureteric reflux occurs in up to 30% of siblings and families. An ultrasound for kidney
size (dysplasia) and scarring is recommended in siblings of children with gross VUR (Grade
4-5) unless normal late ultrasound scans in pregnancy. Discuss with consultant responsible
for the patient.
Andy Lunn
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Paediatric Clinical Guideline
Emergency: 1.1 Cardiopulmonary Resuscitation
Follow-Up Management6
Information Sheet (particularly relevant for recurrent cystitis)
Prevention of urinary tract infections
When your child has a urinary tract infection, the doctor will prescribe antibiotics. As well as
the antibiotics, there are also some things you can do to help the infection to get better and
also prevent another infection.
1. AVOID CONSTIPATION. You can do this by giving your child a high fibre diet to include
wholemeal bread, whole-wheat cereals and fresh fruit and vegetables. Ensure that your
child drinks a lot and has regular exercise. The doctor may also give your child a medicine
to soften the stools.
If your child has any problems with WORMS let the doctor know.
2. In young girls the tube to the bladder is very close to the back passage. WIPING should
be done in a front to back direction.
3. It is better to take a shower rather than a bath. Always avoid irritating soaps and bubble
baths. CLEANLINESS is very important to help prevent infection.
4. EMPTYING THE BLADDER PROPERLY IS VERY IMPORTANT. Encourage
your child to use the toilet regularly and empty the bladder every 2-3 hours.
Sometimes we ask that your child will double empty the bladder. The child will pass
water then wait a few minutes before trying to pass water again.
5. Always encourage your child to DRINK as much as possible during the day, and
to EMPTY THE BLADDER PROPERLY LAST THING AT NIGHT.
6. CORRECT UNDERWEAR. Avoid tight underpants or pantyhose. They prevent
air from circulating freely and encourage the warm, moist environment which
favours infection.
Soft cotton briefs, changed daily, are a far better choice.
Consider changing the washing powder you use for the panties if irritation persists.
7. When taking antibiotics the full course must be taken at the time required. Any
PROBLEMS such as burning when passing water, going to the toilet often, or blood
in the water SHOULD BE REPORTED to the doctor.
We hope that these ideas will help you to help your child. Please do not hesitate to
ask questions or contact us if you are worried.
Contact Name__________________________________
Contact Number 0115 924 9924 ext_________________
See also website – www.childrenskidneynottingham.nhs.uk for information leaflets
Andy Lunn
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Paediatric Clinical Guideline
Emergency: 1.1 Cardiopulmonary Resuscitation
Antibiotic Prophylaxis
1. Not routinely recommended whilst awaiting further investigations. Although systemic
review suggests no discernible benefit from prophylaxis, data are few and further
controlled trials awaited.
2. May be considered in:
 Seriously ill children (NICE guidelines for feverish illness)
 Children with dysfunctional voiding patterns and recurrent urinary tract infections
 Proven vesicoureteric reflux (Grade 3-5 VUR). Prophylaxis is usually maintained for
2 years.
 Frequent UTIs (eg 3 monthly or less) in the absence of proven vesicoureteric reflux.
Trimethoprim is the usual prophylactic agent. If breakthrough infections resistant to this then
a suitable alternative such as Nitrofurantoin or Cephradine may be used.
Hospital follow-up



All patients on prophylactic antibiotics
Unilateral scarring – annual review blood pressure measurements. Repeat ultrasound at
2 years. If normotensive and infection-free at 5 years of age discharge with yearly blood
pressure measurements by GP
Bilateral renal scarring – long-term paediatric nephrology follow-up
Referral to Paediatric Nephrology/Urology





Significant hydronephrosis on ultrasound in the absence of reflux on MCUG
Bilateral reflux nephropathy
Children with dysfunctional voiding patterns in association with recurrent urinary tract
infection
Recurrent urinary tract infections despite antibiotic prophylaxis
Severe vesicoureteric reflux (Grade 3 or above)
References
1. NICE Clinical Guideline CG54 – Urinary tract infection in children: diagnosis, treatment and
long term management: Aug 2007 http://guidance.nice.org.uk/CG54
2. Somers J. The radiology of childhood UTI. Radiology Update CME Journal 2001;2(2):65-77
3. Barry BP, Hall N, Cornford E, Broderick NJ, Somers JM, Rose DH. Improved ultrasound
detection of renal scarring in children following urinary tract infection. Clin Radiol
1998;53:747-751
4. NICE Clinical Guideline CG47 – Feverish illness in children. May 2007
http://guidance.nice.org.uk/CG47
5. Montini G, Toffolo A, Zucchetta P et al. Antibiotic treatment for pyelonephritis in children:
multicentre randomised controlled non-inferiority trial. BMJ 2007;335;386
6. Watson AR. In: McIntosh N, Helms P, Smyth R (eds) Forfar & Arneil’s Textbook of
Pediatrics (edition 6), Urinary tract infections 2003 pp613-620. Churchill Livingstone
Edinburgh
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Paediatric Clinical Guideline
Emergency: 1.1 Cardiopulmonary Resuscitation
Appendix 1 – Traffic Light System for Identifying Risk of Serious Illness (NICE
CG47)
Children with fever and any of the symptoms or signs in the ‘red’ column should be
recognised as being at high risk. Similarly, children with fever and any of the symptoms or
signs in the ‘amber’ column and none in the ‘red’ column should be recognised as being at
intermediate risk. Children with symptoms and signs in the ‘green’ column and none in the
‘amber’ or ‘red’ columns are at low risk. The management of children with fever should be
directed by the level of risk.
Green – low risk
Colour
Activity
 Normal colour of
skin, lips and
tongue
 Responds normally
to social cues
 Content/smiles
 Stays awake or
awakens quickly
 Strong normal cry/
not crying
Respiratory
Hydration
 Normal skin and
eyes
 Moist mucous
membranes
Other
 None of the amber
or red symptoms or
signs
Amber
–
intermediate risk
 Pallor reported by
parent/carer
Red – high risk
 Not responding
normally to social
cues
 Wakes only with
stimulation
 Decreased activity
 No smile
 No response to social
cues
 Appears ill to a
healthcare professional
 Does not wake or if
roused does not stay
awake
 Weak, high-pitched or
continuous cry
 Grunting
 Tachypnoea:
RR > 60 breaths/min
 Moderate or severe
chest indrawing
 Nasal flaring
 Tachypnoea:
RR > 50
breaths/min,
Age 6-12 months
RR > 40
breaths/min,
Age > 12 months
 Oxygen saturation
≤ 95% in air
 Crackles
 Dry mucous
membranes
 Poor feeding in
infants
 CRT ≥ 3 seconds
 Reduced urine
output
 Fever for ≥ 5 days
 Swelling of a limb
or joint
 Non-weight
bearing/ not using
an extremity
 A new lump > 2 cm
CRT = capillary refill time; RR = respiratory rate
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 Pale/mottled/ashen/
blue
 Reduced skin turgor
 Age 0-3 months,
temperature ≥ 38oC
 Age 3-6 months,
temperature ≥39oC
 Non-blanching rash
 Bulging fontanelle
 Neck stiffness
 Status epilepticus
 Focal neurological
signs
 Focal seizures
 Bile-stained vomiting
January 2007