Yorkshire Regional Guidelines for the Management of Urinary Tract Infections in Childhood

• Main Guideline

 Index: “How to use these guidelines”

• Who is this guideline aimed at and why is it important to diagnose UTI in childhood?
• When should a UTI be suspected and how do I collect a urine sample to confirm the diagnosis?
• Which children require urgent admission to hospital?
• How should I treat UTIs and what are the indications for intravenous antibiotics?
• What are the indications for urgent and follow-up radiological investigations?
• Which children require follow up by a General Paediatrician?
• Which children should be referred to a Tertiary Paediatric Nephrologist in Leeds?
• Who do I contact for more information about this guideline?
• Suggested Audit Points
• Glossary

Scope of Guidelines

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Theses guidelines are aimed for use by all health care practitioners in the management of urinary tract infections in all infants and children less than 16 years of age.

Introduction

3-5% of girls and 1-2% of boys will have a symptomatic UTI during childhood. Symptoms and signs of UTI are often non specific especially under 3 years. Infection not only causes troublesome and often recurrent symptoms but also may point to unsuspected abnormalities of the urinary tract. The most common of these is vesicoureteric reflux (VUR). In a minority of cases VUR in association with a UTI can result in reflux nephropathy and potentially chronic renal failure in late childhood or adult life. However current management, subjects a large number of children to often unpleasant investigations, antibiotic prophylaxis and prolonged follow up based on limited evidence. This has also placed a heavy burden on the NHS.
These Regional Guidelines are based upon NICE clinical guideline 54, “Urinary tract infection in children: diagnosis, treatment and long-term management.” www.nice.org.uk/CG054.
Any deviation from NICE will be clearly stated in text. The NICE Quick reference guide (QR) can also be used for supplementary information where referenced within this regional guideline.
This guideline also refers to NICE clinical guideline 47, “Feverish illness in children: assessment and initial management in children younger than 5 years.” www.nice.org.uk/CG047

Aims

The aim of these guidelines in conjunction with NICE is to achieve more consistent clinical practice, based on accurate diagnosis and effective management. However the clinician (having read the guideline) has to take responsibility for their clinical management and therefore may refer, investigate and treat as they feel appropriate for individual patients. This may be particularly applicable to infants < 1year who may warrant referral to local paediatric services.

Diagnosis

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Symptoms and signs:
UTI is a common bacterial infection causing illness in infants and children. It may be difficult to recognise UTI in children because the presenting symptoms and/or signs are non-specific, particularly in the youngest children.

Test urine sample in infants and children: (QR p8) 

• with symptoms and signs of UTI (from table above)
• with unexplained fever of 38°C or higher
• with an alternative site of infection but who remain unwell
• All infants younger than 3 months with suspected UTI should be referred to paediatric specialist care and a urine should be sent for urgent microscopy and culture

Management

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Method of collecting urine sample:

• 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 bags/ urine collection pads should be used. It is important to follow the manufacturers’ instructions when using urine collection pads / bags.
• 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 when possible to demonstrate the presence of urine in the bladder.
• In an acutely unwell child it is highly preferable that a urine sample is obtained; however, treatment should not be delayed if a urine sample is unobtainable.

Testing and preserving urine samples:

• All urine should be collected in universal white top container first and then dipsticked for the presence of Nitrite and Leukocytes
• All children should have urine sent for MC&S if there is strong clinical suspicion or any abnormalities on testing for leucocytes or nitrites
• Before sending to the laboratory - Transfer urine from universal container (white topped) to boric acid container (red topped). Samples can be stored in a boric acid container for up to 48hrs at room temperature. There is no need to refrigerate. Ensure patient details are completed along with referring clinician to allow processing of sample and communication of results.

Microbiology results
A growth of 10⁵organisms/ml of single bacteria on a CCU/MSU is the bacteriological criterion for UTI Diagnosis. Any growth on a SPA is considered significant.

Assessment of significant risk factors in children with UTI
The following risk factors for UTI and serious underlying pathology should be recorded:

Treatment

1. Infants younger than 3 months with a possible UTI and any child with a high risk of serious illness should be referred immediately to the care of a general paediatrician.
2. The use of an oral antibiotic with low resistance patterns is recommended, for example cephalosporin. Adjust antibiotics if required once urine culture and sensitivity results available.
3. If oral antibiotics cannot be used, treat with an intravenous (IV) antibiotic agent such as cefuroxime for 2-4 days followed by oral antibiotics for a total duration of 10 days.
4. 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.

Imaging strategies

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Definitions:

Follow-up (QR p14)

Agree how to communicate the results of imaging tests with parents/ carers.

Infants and children who do not undergo imaging investigations should not be routinely followed up.

• Antibiotic prophylaxis is not routinely recommended in children with their first UTI.
• When MCUG is performed, prophylactic antibiotics should be given orally for 3 days with MCUG taking place on the second day
• All parents/carers should be advised to be vigilant during illness for non specific symptoms of malaise and unexplained fevers which may be due to a further UTI and would need prompt investigation and treatment.
• Parents/carers should have methods of collecting urine from child to get tested by local primary care doctor.

Indications for referral to Local General Paediatric Services:

1. All children under the age of 3 months
2. Children of any age who are systemically unwell
3. Children with recurrent UTI

Assessment In General Paediatrics should:

• Address dysfunctional elimination syndromes and constipation
• Include height, weight, blood pressure and routine testing for proteinuria. This should be performed at least on a yearly basis in all infants and children with renal parenchymal defects.

Indications for referral to Tertiary Paediatric Nephrology:

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1. Bilateral parenchymal abnormalities
2. Impaired renal function
3. Hypertension
4. Proteinuria