UTI in Children
Definition: Urinary tract infection (UTI) is an illness caused by micro-organisms in the urinary tract. UTI is considered abnormal if there is serious illness, poor urine flow, abdominal or bladder mass, raised creatinine, sepsis, failure to respond to treatment within 48 hours or infection with non-E coli organism.
When to suspect
Risk factors
Age below one year
Female
Previous UTI
Voiding dysfunction
Vesicoureteral reflux (VUR), family history of VUR or renal disease
Sexual activity
No history of breastfeeding
Immunosuppression
Lower UTI children under three months - fever, vomiting, lethargy, irritability, poor feeding or failure to thrive. Less common - abdominal pain, jaundice, haematuria and/or offensive urine.
Lower UTI over 3 months - fever, frequency, dysuria, abdominal pain, loin tenderness, vomiting, poor feeding, dysfunctional voiding, changes to continence. Less common lethargy, irritability, haematuria, offensive urine, failure to thrive, malaise or cloudy urine.
Suspect pyelonephritis - unexplained fever or 38 or more, or loin pain/tenderness
Multiple symptoms and signs will probably increase the likelihood that there is a UTI.
It may be useful to consider alternative diagnoses where the symptoms and signs decrease the likelihood that a UTI is present.
Symptoms which decrease likelihood of UTI - absence of painful urination, nappy rash, breathing difficulties, abnormal chest sounds, abnormal ear examination or fever with an alternative cause.
Diagnosis of UTI
Diagnose acute pyelonephritis/upper UTI in children with: fever 38 or higher and bacteriuria or fever lower than 38 with loin pain/tenderness and bacteriuria.
If UTI is suspected in children aged under 3 months — refer urgently to a paediatric specialist for treatment with parenteral antibiotics, and send a urine sample for urgent microscopy and culture.
For all children presenting with an unexplained fever of 38ºC or higher, or loin pain/tenderness suggesting pyelonephritis — send a urine sample for microscopy and culture within 24 hours, and consider referral to a paediatric specialist.
If UTI is suspected in children aged 3 months or over — perform dipstick analysis.
Make an assessment of the risk of serious illness in all children with suspected urinary tract infection (UTI) — if the risk is high, refer urgently to secondary care.
If both leukocyte esterase and nitrite are negative, UTI is unlikely - UTI unlikely, consider differential diagnosis, send urine sample for culture and sensitivity.
If both leukocyte esterase and nitrite are positive, treat as a UTI - start antibiotic and send urine sample for culture and sensitivity.
If leukocyte esterase is positive and nitrite is negative, send a urine sample for microscopy and culture - for children under 3 start antibiotic treatment and reassess when results returned, over 3 only start antibiotic treatment if there is good clinical evidence of a UTI.
If leukocyte esterase is negative and nitrite is positive, treat as a UTI - start an antibiotic if urine was fresh, send sample to confirm diagnosis.
Consider testing the urine of children aged over 3 months if they are unwell and there is a suspicion of UTI, but none of the signs and symptoms.
Do not delay treatment in a child with a high risk of serious illness if a urine sample cannot be obtained.
Differential diagnosis
Nephrolithiasis
Meningitis
Sepsis with no urinary tract source
Threadworms
Kawasaki disease
Interstitial cystitis
Urethritis
Vulvovaginitis or vaginal foreign body
Voiding dysfunction
Although it is rare, clinicians should be alert to the possibility of child abuse presenting with urinary symptoms.
Management UTI
Arrange ultrasound of the urinary tract if atypical infection indicated by - poor urine flow, abdominal or bladder mass, raised creatinine, sepsis, failure to respond to treatment.
Provide parents or carers with information or advice - advice on completing treatment, seek further advice if do not respond to treatment, use of paracetamol/ibuprofen, adequate fluid intake, do not delay voiding.
For all children 3 months or older with cystitis/lower UTI: start oral antibiotic treatment - first line options include Trimethoprim or Nitrofurantoin.
Children 3 months of older with acute pyelonephritis/upper UTI: use clinical judgement to determine in referral to paediatric specialist required. Start oral antibiotic only when culture results available and sensitive - Cefalexin or Co-Amoxiclav.
If UTI is suspected in children aged under 3 months — refer urgently to a paediatric specialist for treatment with parenteral antibiotics, and send a urine sample for urgent microscopy and culture.
If the child has been assessed at high risk of serious illness, refer urgently to secondary care.
Management recurrent UTI
Ensure that a dimercaptosuccinic acid scintigraphy (DMSA) scan to detect renal parenchymal defects is carried out within 4–6 months following the acute infection in all children with recurrent UTI.
Arrange ultrasound of urinary tract.
Refer all children with recurrent UTI to a paediatric specialist for assessment and investigations.
If trial of daily prophylaxis antibiotic given - give information on risk of resistance, possible adverse effects, returning for review in 6 months and seeking medical help in acute symptoms.
For children aged 3 months or over with recurrent UTI, ensure that any current UTI has been adequately treated, then take specialist advice and consider a trial of daily antibiotic prophylaxis, if behavioural and personal hygiene measures alone are not effective or not appropriate.
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.