urinary tract infection in children management and referral

Version 4.3 Jan 19 - Review March 2022 Author(s) R Bragonier Consultant General Paediatrician, J Dudley Consultant Paediatric Nephrologist of 10

Clinical Guideline

URINARY TRACT INFECTION (UTI) IN CHILDREN - MANAGEMENT AND REFERRAL

SETTING Bristol Royal Hospital for Children (BRHC)

FOR STAFF Medical and nursing

PATIENTS Children in BRHC with suspected or confirmed UTI

Background: This guidance is adapted from National Institute of Care Excellence (NICE) guidance CG54 (2007, updated 2017)

Important practice points

• In suspected UTI, prompt antibiotic treatment after obtaining urine culture will reduce riskof subsequent renal scarring

• Many children no longer need paediatric referral following UTI – see Algorithms• Prophylactic antibiotics are no longer routinely indicated following first UTI• Less extensive imaging is required in children >6 months than previously – see Algorithms• Search for and treat underlying constipation

Suspect diagnosis Age-related symptoms –Section A

Collect urine Preferred collection methods - Section B

Test/send sample Predictive value of stick test - Section C

Treat appropriately Cystitis or Pyelonephritis? - Section D

Acute referral criteria & antibiotics – Section E

Scan, refer and follow-up as needed Algorithms for scanning/referral - Section F

Follow-up - Section G

Next review date March 2022

Version 4.3 Jan 19 - Review March 2022 Author(s) R Bragonier Consultant General Paediatrician, J Dudley Consultant Paediatric Nephrologist of 10

Section A – Symptoms and signs by age

Age Most common Least common

< 3months

Unexplained fever

Vomiting

Lethargy

Irritability

Poor feeding

Faltering growth

Abdominal pain

Jaundice

Haematuria

Offensive urine

Preverbal

(infants & toddlers) Fever

Abdominal pain

Loin tenderness

Vomiting

Poor feeding

Lethargy

Irritability

Haematuria

Offensive urine

Faltering growth

Verbal

(children)

Frequency

Dysuria

Dysfunctional voiding

Deterioration in continence

Abdominal pain

Loin tenderness

Fever

Malaise

Vomiting

Haematuria

Offensive or cloudy urine

Infants, children and young people with a urinary tract infection should have the following risk factors for urinary tract infection and serious underlying pathology recorded as part of their history and examination:

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

Section B – Urine collection

Test if:

Unexplained fever >38C, in any age child, within 24 hours of onset

Symptoms/signs suggesting UTI (above)

Feverish illness due to apparent other cause, but not improving


Version 4.3 Jan 19 - Review Dec 2020 Author(s) R Bragonier Consultant General Paediatrician, J Dudley Consultant Paediatric Nephrologist of 10

Nitrite +ve Nitrite -ve

Leukocyte esterase +ve UTI highly likely, send for MC&S, start treatment

UTI likely, send for MC&S, start treatment

Leukocyte esterase -ve UTI likely if freshly voided sample, send for MC&S, start treatment

No UTI, do not send for MC&S unless strong suspicion of UTI

Pyruria No pyuria

Bacteriuria UTI, start treatment Regard as UTI, start treatment

No Bacteriuria Treat if clinically has UTI No UTI

Collect by:

'Clean catch' recommended and best practice. Bag specimens strongly discouraged (highincidence of contamination).

If 'clean catch' not possible, use special collection pads (not cotton wool balls, sanitary towels,gauze).e.g. 'Uricol' Newcastle Urine Collection kits.

If neither possible, consider catheterisation (CSU), or supra-pubic aspiration (SPA), ideally underultrasound guidance, in hospital.

If child very unwell, do not delay antibiotics while awaiting specimen.

Sample storage:

Plain container, if can be cultured in lab within 4 hours

Otherwise, refrigerate sample or use Boric acid container (must be over half full)

Section C – Urine testing

Stick testing for nitrites and leukocyte esterase is helpful in excluding UTI and for predictingpositive culture in children over 3 months. Interpretation of stick test is age-dependent (see tablebelow)

But remember stick testing unreliable <3 months old (normal frequent passage of urinedoesn't allow time for nitrite formation). NICE suggests referral to secondary care if UTIsuspected under 3 months.

Use clinical criteria for decision-making in cases where urine stick testing does not support clinicalfindings

Predictive value of dipstick and microscopy:

DIPSTICK (3months – 3years)

DIPSTICK (over 3 years) Nitrite +ve Nitrite -ve

Leukocyte esterase +ve UTI highly likely, send for MC&S, start treatment

May be due to infection elsewhere, send for MC&S, do not start treatment unless strong clinical suspicion of UTI

Leukocyte esterase -ve UTI likely if freshly voided sample, send for MC&S, start treatment

No UTI, do not send for MC&S unless strong suspicion of UTI

MICROSCOPY (all ages)



Indications for sending sample for MC&S:

Suspected pyelonephritis (upper tract infection)

Patient very unwell

All cases <3months where UTI is suspected (remember sticks unreliable <3months)

Nitrite and/or Leukocyte esterase positive on stick test (as in tables above)

Recurrent UTIs

Suspected UTI unresponsive to treatment after 24 - 48 hours

Clinical symptoms strongly suggest UTI but stick test doesn't correlate

Section D - Pyelonephritis (upper tract infection) or Cystitis (lower tract)?

Acute pyelonephritis

Cystitis

Bacteriuria/+ve stick test and fever >38C

Bacteriuria/+ve stick test plus loin pain/tenderness, irrespective of fever

Bacteriuria/+ve stick test but fever <38C and no systemic symptoms (e.g. vomiting, loin pain/tenderness)

Section E – Treatment Please refer to the BRHC empirical medical antibiotic guidelines.

Do:

1. Change to new antibiotic if patient already taking antibiotic prophylaxis (revert to usual prophylaxis once UTI cleared)

2. Prevent further UTIs by: a. Treating any coexisting constipation b. Advising increase fluid intake c. Discouraging delayed bladder voiding

3. Give families of children who have had confirmed UTIs information about how to recognise re- infection (section A) and to seek medical advice straight away.

Don't: Treat asymptomatic bacteriuria

Commence antibiotic prophylaxis after single UTI (consider if recurrent)


http://nww.avon.nhs.uk/dms/download.aspx?did=6081


Section F – Scanning and referral

For definitions of 'Atypical' and 'Recurrent' UTIs, and abbreviations used in these algorithms, see below.

'Atypical' UTI

Any of:

'Seriously ill' with UTI

Poor urine flow

Non-response to first 48 hours treatment

Non E coli infection

Septicaemia

Abdominal/bladder mass

Raised Creatinine

'Recurrent' UTI

2 or more 'upper tract' (pyelonephritis) UTIs

1 'upper tract' (pyelonephritis) and 1 'lower tract' (cystitis) UTI

3 or more lower tract (cystitis) UTIs

U/S

Renal tract ultrasound

Can be requested from:

Bristol Royal Hospital for Children (North Bristol GPs can arrange UHB ICE ordering access via their practice managers)

Weston General Hospital

If continent, also request 'bladder emptying' on form

MCUG

Micturating cysto-urethrogram (for detecting VUR and posterior urethral valves)

MCUG antibiotic prophylaxis

Trimethoprim 4mg/kg/dose BD for 3 days, with MCUG on 2nd

day

DMSA

Dimercaptosuccinic acid or static renal scan (for detecting relative function and scarring)

VUR

Vesico-ureteric reflux



Imaging requirements: Children 0 - 6 months

Responds well to treatment within 48 hours

‘Atypical’ ‘Recurrent’

U/S within 6 weeks U/S during acute episode

Normal Abnormal Refer to General Paediatrics

No follow-up

MCUG (with covering antibiotic prophylaxis)

DMSA 4 – 6 months after (most recent) UTI



Imaging requirements: Children 6 months - 3 years

Responds well to treatment within

48 hours

'Atypical' 'Recurrent'

Non E coli UTI, responding within 48 hours, with no other 'atypical' features

No investigation or follow-up

U/S during acute episode

Refer to General Paediatrics

U/S within 6 weeks

Refer to General

Paediatrics


Consider MCUG (with covering antibiotic prophylaxis) if any of: dilatation on U/S, poor urine stream, non E coli

UTI, family history of VUR



Imaging requirements: Children over 3 years

Responds well to treatment within

48 hours

'Atypical' 'Recurrent'

Non E coli UTI, responding

within 48 hours, with no other atypical features

U/S during acute episode, specifically requesting

'bladder emptying' assessment as well

U/S within 6 weeks, specifically requesting

'bladder emptying' assessment as well

U/S normal U/S abnormal

No other

investigation or follow-up

Refer to General Paediatrics




Section G – Follow-up (all ages)

No follow-up required if:

No imaging tests performed

Normal imaging (unless recurrent UTIs - below)

Follow-up if:

Recurrent UTIs, even if normal imaging

Abnormal imaging

Impaired renal function

Persistent proteinuria

Suggested follow-up plan

Monitor, at least annually:

Height

Weight

Blood pressure

Proteinuria

RELATED DOCUMENTS

NICE CG54 http://publications.nice.org.uk/urinary-tract-infection-in-children- cg54 NICE QS36 http://guidance.nice.org.uk/QS36 BRHC empirical medical antibiotic guidelines

AUTHORISING Paediatric Medicine Governance Group

BODY

SAFETY

QUERIES


http://publications.nice.org.uk/urinary-tract-infection-in-children-cg54



http://guidance.nice.org.uk/QS36

http://nww.avon.nhs.uk/dms/download.aspx?did=6081

urinary tract infection in children management and referral

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