Management of Urinary tract infection in Childhood – Based NICE

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Management of Urinary tract infection in Childhood – Based NICE 54 (Aug07)
1. History and Examination
To include recording presence or absence: poor urine flow, previous UTI or recurrent PUO,
antenatal anomalies, FH of ureteric reflux or kidney disease, constipation, dysfunctional voiding,
enlarged bladder, abdominal mass, evidence of spinal anomaly, poor growth , high blood
pressure
2. Obtain urine for testing
Clean catch urines should be obtained from all children with unexplained fever greater than 38
deg C or symptoms or signs of UTI: vomiting, frequency, dysuria, poor feeding, failure to thrive,
abdo pain, acute incontinence, malaise, offensive urine – Supply sterile galipot while waiting
Alternatives to clean catch such as bag urine, CSU and SPA should only be used if clean catch
not possible. E.g. urgent full infection screen indicated in young child – SPA should always use
ultrasound to confirm urine in bladder
3. Testing urine
Less than 3 years – send for urgent microscopy and culture
Over 3 years – Use dipstick to diagnose UTI
Managing results:
Microscopy less than 3 years:
Bacturia positive
Bacturia negative
Leucocytes positive
UTI
UTI if supportive signs
Leucocytes neg.
UTI
Not UTI
Dipstick – over 3 years
Leuc + nitr+
Treat send for culture if previous infection or risk of serious illness
Leuc – nitr +
Treat send for culture
Leuc + nitr Send for culture treat only if good clinical evidence
Leuc – nitr Do not treat Do not send for culture unless recurrent
4. Treatment
Less than 3 months – treat as per childhood fever – full septic screen and iv antibiotics
Over three months and unwell –
7- 10 day oral antibiotics – trimethoprim
If not tolerated or septicaemic then iv cefuroxime
Over three months,if bacturia /dysuria frequency alone with no systemic features- cystitis trimethoprim 3 days only)
5. Further Investigations:
Child < 6 months:
USS within 6 weeks alone unless:
Atypical or recurrent: Urgent USS, MCUG as OPD, DMSA @ 4-6
months
6 month -3 years:
no investigations unless:
Atypical – Urgent USS, DMSA @4-6 month
Recurrent – USS within 6 weeks, DMSA @4-6 month
Child > 3 years:
No investigations unless:
Atypical - Urgent USS
Recurrent – USS within 6 weeks DMSA @ 4-6 months
Definitions:
Atypical : severely ill, poor urine flow, abdominal or bladder mass, raised creatanine,
septicaemia, failure to respond to antibiotics within 48 hrs, infection with non E.coli organisms
Recurrent: one Pylonephritis plus any other UTI or three cystitis ( pylonephritis = bacturia with
fever or loin pain)
6. Prophylaxis – not covered in NICE guideline (trimethoprim 2 mg kg nocte)
Recurrent UTI – 6 weeks pending ultrasound, consider 3 months treatment if
2 infections in 3 months
Known antenatal renal tract dilatation – until resolved or 2 years
Proven renal scar – until 4 years
7. Follow up:
No follow up: if no investigations or if investigations are normal (letter to parents)
Recurrent UTI or with abnormal tests – follow up at 3 months – if scar need growth blood
pressure and proteinuria screening (unilateral small scar use judgement)
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