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Urinary tract infection in children: diagnosis, treatment and long-term management

National Institute for Health and Care Excellence

Key priorities for implementation

  • Infants and children presenting with unexplained fever of 38°C or higher should have a urine sample tested 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. Table 1 is a guide to the symptoms and signs that infants and children present with
  • 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 manufacturers’ 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
  • The urine-testing strategies shown in the tables below
  • 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

Table 1: Presenting symptoms and signs in infants and children with UTI

Age group Symptoms and signs

Most common <-------------------> Least common
Infants younger than 3 months Fever
Vomiting
Lethargy
Irritability 		Poor feeding
Failure to thrive 		Abdominal pain
Jaundice
Haematuria
Offensive urine
Infants and children,
3 months or older		 Preverbal Fever Abdominal pain
Loin tenderness
 Vomiting
Poor feeding 		Lethargy
Irritability
Haematuria
Offensive urine
Failure to thrive
Verbal Frequency
Dysuria 		Fever
Malaise
Vomiting
Haematuria
Offensive urine
Cloudy urine
  • 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 a paediatric specialist
    • 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
  • Antibiotic prophylaxis should not be routinely recommended in infants and children following first-time UTI
  • Infants and children who have had a UTI should be imaged as outlined in Tables 2 and 4

Urinary tract infection in children: diagnosis, treatment and long-term management continued

Table 2 Urine-testing strategies for infants and children

Urine testing strategies
Infants younger than 3 months Refer to paediatric specialist care Urine sample for urgent microscopy and culture. Manage in line with ‘Feverish illness in children’ (NICE clinical guideline 47)
Infants and children 3 months or older but younger than 3 years Use urgent microscopy and culture to diagnose UTI
Specific urinary symptoms Urine sample for urgent microscopy and culture Start antibiotic treatment If urgent microscopy is not available, send a urine sample for microscopy and culture, and start antibiotic treatment
Non-specific symptoms

High risk of serious illness:
Urgent referral to paediatric specialist care

Urine sample for urgent microscopy and culture

Manage in line with ‘Feverish illness in children’ (NICE clinical guideline 47)

Intermediate risk of serious illness:
Consider urgent referral to a paediatric specialist as described in ‘Feverish illness in children’ (NICE clinical guideline 47)

When specialist paediatric referral is not required:

  • urgent microscopy and culture should be arranged
  • antibiotic treatment should be started if microscopy is positive
  • when urgent microscopy is not available, dipstick testing may be used as a substitute
  • the presence of nitrites suggests the possibility of infection and antibiotic treatment should be started

In all cases, a urine sample should be sent for microscopy and culture

Low risk of serious illness:
 Urine sample for microscopy and culture.

Start antibiotic treatment if microscopy or culture is positive

 Table 3: Urine-testing strategies for children 3 years or older

Esterase

Nitrate

Use dipstick test to diagnose UTI

+

+

Start antibiotic treatment for UTI
 If high or intermediate risk of serious illness or past history of UTI, send urine sample

-

+

Start antibiotic treatment if fresh sample was tested
 Send urine sample for culture

+

-

Send urine sample for microscopy and culture
 Only start antibiotic treatment for UTI if there is good clinical evidence of UTI
 Result may indicate infection elsewhere
 Treat depending on results of culture

-

-

Do not start treatment for UTI
 Explore other causes of illness
 Do not send urine sample for culture unless recommended in ‘Indications for culture’

Table 4: Guidance on the interpretation of microscopy results

MIcroscopy results

Pyuria positive

Pyuria negative

Bacteria positive

The infant or child should be regarded as having UTI

The infant or child should be regarded as having UTI

Bacteriuria negative

Antibiotic treatment should be started if clinically UTI

The infant or child should be regarded as not having UTI

Urinary tract infection in children: diagnosis, treatment and long-term management continued

Definitions of atypical and recurrent UTI

  • Atypical UTI includes:
    • seriously ill (for more information refer to ‘Feverish illness in children’ [NICE clinical guideline 47]
    • poor urine flow
    • abdominal or bladder mass
    • raised creatinine
    • septicaemia
    • failure to respond to treatment with suitable antibiotics within 48 hours
    • infection with non-E. coli organisms
  • Recurrent UTI:
    • two 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 episode of UTI with cystitis/lower urinary tract infection, or
    • three or more episodes of UTI with cystitis/lower urinary tract infection

Table 5: Recommended imaging schedule

Test

Responds well to treatment within 48 hours

Atypical UTIa

Recurrent UTIa

for infants younger than 6 months

Ultrasound during the acute infection

No

Yesc

Yes

Ultrasound within 6 weeks

Yesb

No

No

DMSA 4–6 months following the acute infection

No

Yes

Yes

MCUG

No

Yes

Yes

for infants and children 6 months or older but younger than 3 years

Ultrasound during the acute infection

No

Yes

No

Ultrasound within 6 weeks

No

No

Yes

DMSA 4–6 months following the acute infection

No

Yes

Yes

MCUG

No

No

Nod

for children 3 years or older

Ultrasound during the acute infection

No

Yesce

No

Ultrasound within 6 weeks

No

No

Yesb

DMSA 4–6 months following the acute infection

No

No

Yes

MCUG

No

No

No

aSee text for definitions
bIf 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
dWhile 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
eUltrasound in toilet-trained children should be performed with a full bladder with an estimate of bladder volume before and after micturition

full guideline available from…
National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, M1 4BT
guidance.nice.org.uk/CG54

National Institute for Health and Care Excellence. Urinary tract infection in children: diagnosis, treatment and long-term
management. Quick Reference Guide. August 2007

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eGuidelines.co.uk (30 June 2013)
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First included: Oct 07.
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