• National Collaborating Centre for Women's and Children's Health. Urinary tract infection in children: diagnosis, treatment and long-term management. London (UK): National Institute for Health and Clinical Excellence (NICE); 2007 Aug. 148 p. (Clinical guideline; no. 54). [271 references]

This is the current release of the guideline.

Diagnosis

Symptoms and Signs

Infants and children presenting with unexplained fever of 38 degrees C or higher should have a urine sample tested after 24 hours at the latest.

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. The Table below is a guide to the symptoms and signs that infants and children present with.

Table. Presenting Symptoms and Signs in Infants and Children with UTI

Assessment of Risk of Serious Illness

The illness level in infants and children should be assessed in accordance with recommendations in "Feverish illness in children" (NICE clinical guideline 47).

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

The urine-testing strategies shown in the Tables below are recommended.*

As with 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.

*Assess the risk of serious illness in line with "Feverish illness in children" (NICE clinical guideline 47) to ensure appropriate urine tests and interpretation, both of which depend on the child's age and risk of serious illness.

Table. Urine-testing Strategy for Infants Younger Than 3 Months

Table. Urine-testing Strategies for Infants and Children 3 Months or Older But Younger Than 3 Years

Table. Urine-testing Strategies for Children 3 Years or Older

Table. Guidance on the Interpretation of Microscopy Results

Indication for Culture

Urine samples should be sent for culture:

• In infants and children who have a diagnosis of acute pyelonephritis/upper urinary tract infection
• In infants and children with a high to intermediate risk of serious illness
• In infants and children younger than 3 years
• In infants and children with a single positive result for leucocyte 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 degrees C or higher should be considered to have acute pyelonephritis/upper urinary tract infection. Infants and children presenting with fever lower than 38 degrees C with loin pain/tenderness and bacteriuria should 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.

Imaging Tests for Localising UTI

The routine use of imaging in the localisation of a UTI is not recommended.

In the rare instances when it is clinically important to confirm or exclude acute pyelonephritis/ upper urinary tract infection, power Doppler ultrasound is recommended. When this is not available or the diagnosis still cannot be confirmed, a dimercaptosuccinic acid (DMSA) scintigraphy scan is recommended.

Acute Management

Note that the antibiotic requirements for infants and children with conditions that are outside the scope of this guideline (for example, 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 "Feverish illness in children" (NICE clinical guideline 47).

For infants and children 3 months or older with acute pyelonephritis/upper urinary tract infection:

• Consider referral to secondary care.
• 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 IV 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.

Long-term Management

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.

Imaging Tests

Infants and children with atypical UTI (see the Table below titled "Definitions of Atypical and Recurrent UTI") should have ultrasound of the urinary tract during the acute infection to identify structural abnormalities of the urinary tract such as obstruction as outlined in Tables below titled "Recommended Imaging Schedule for Infants Younger Than 6 Months," "Recommended Imaging Schedule for Infants and Children 6 months or Older But Younger Than 3 Years," and "Recommended Imaging Schedule for Children 3 Years or Older." This is to ensure prompt management.

For infants younger than 6 months with first-time UTI that responds to treatment, ultrasound should be carried out within 6 weeks of the UTI, as outlined in the Table below titled "Recommended Imaging Schedule for Infants Younger Than 6 Months."

For infants and children 6 months or older with first-time UTI that responds to treatment, routine ultrasound is not recommended unless the infant or child has atypical UTI, as outlined in the Tables below titled "Recommended Imaging Schedule for Infants and Children 6 months or Older But Younger Than 3 Years" and "Recommended Imaging Schedule for Children 3 Years or Older."

Infants and children who have had a lower urinary tract infection should undergo ultrasound (within 6 weeks) only if they are younger than 6 months or have had recurrent infections.

A DMSA scan 4–6 months following the acute infection should be used to detect renal parenchymal defects as outlined in the Tables below titled "Recommended Imaging Schedule for Infants Younger Than 6 Months," "Recommended Imaging Schedule for Infants and Children 6 months or Older But Younger Than 3 Years," and "Recommended Imaging Schedule for Children 3 Years or Older."

If the infant or child has a subsequent UTI while awaiting DMSA, the timing of the DMSA should be reviewed and consideration given to doing it sooner.

Routine imaging to identify VUR is not recommended for infants and children who have had a UTI, except in specific circumstances as outlined in the Tables below titled "Recommended Imaging Schedule for Infants Younger Than 6 Months," "Recommended Imaging Schedule for Infants and Children 6 months or Older But Younger Than 3 Years," and "Recommended Imaging Schedule for Children 3 Years or Older."

When micturating cystourethrogram (MCUG) is performed, prophylactic antibiotics should be given orally for 3 days with MCUG taking place on the second day.

Infants and children who have had a UTI should be imaged as outlined in the Tables below titled "'Recommended Imaging Schedule for Infants Younger Than 6 Months," "Recommended Imaging Schedule for Infants and Children 6 months or Older But Younger Than 3 Years," and "Recommended Imaging Schedule for Children 3 Years or Older."

Table. Definitions of Atypical and Recurrent UTI

Table. Recommended Imaging Schedule for Infants Younger Than 6 Months

^aSee the Table titled "Definitions of Atypical and Recurrent UTI," above, for definition.

^b If abnormal consider MCUG.

^cIn an infant or 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.

Table. Recommended Imaging Schedule for Infants and Children 6 Months or Older But Younger Than 3 Years

^aSee the Table titled "Definitions of Atypical and Recurrent UTI," above, for definition.

^bWhile 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 infection
• Family history of VUR

^cIn an infant or 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.

Table. Recommended Imaging Schedule for Children 3 Years or Older

^aSee the Table titled "Definitions of Atypical and Recurrent UTI," above, for definition.

^bUltrasound in toilet-trained children should be performed with a full bladder with an estimate of bladder volume before and after micturition.

^cIn 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.

Surgical Intervention for VUR

Surgical management of VUR is not routinely recommended.

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 to Children, Young People, and Parents/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 to be vigilant 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

A clinical algorithm for "Diagnosis, Treatment and Long-Term Management of Urinary Tract Infection in Infants and Children" is provided in the original guideline document.

The type of evidence supporting the recommendations is not specifically stated.

• National Collaborating Centre for Women's and Children's Health. Urinary tract infection in children: diagnosis, treatment and long-term management. London (UK): National Institute for Health and Clinical Excellence (NICE); 2007 Aug. 148 p. (Clinical guideline; no. 54). [271 references]

Not applicable: The guideline was not adapted from another source.

2007 Aug

National Collaborating Centre for Women's and Children's Health - National Government Agency [Non-U.S.]

National Institute for Health and Clinical Excellence (NICE)

Guideline Development Group

Group Members: Kate Verrier Jones, Reader in Child Health (GDG Lead); Jay Banerjee, Consultant in Adult and Paediatric Emergency Medicine; Su-Anna Boddy, Consultant Paediatric Urologist; David Grier, Consultant Radiologist; Lyda Jadresic, Consultant Paediatrician; James Larcombe, General Practitioner; Julie Marriott, Patient/Carer Representative; Jeni Senior, Paediatric Urology Specialist Nurse; Kjell Tullus, Consultant Paediatric Nephrologist; Sue Vernon, Senior Paediatric Nurse, UTI Direct Access Service; Craig Williams, Consultant Microbiologist

All Guideline Development Group (GDG) members' interests were recorded on a standard declaration form that covered consultancies, fee-paid work, shareholdings, fellowships, and support from the healthcare industry in accordance with guidance from the National Institute for Health and Clinical Excellence (NICE).

This is the current release of the guideline.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.