Management of Urinary tract infection in Childhood – Based NICE 54 (Aug07)

1. History and Examination

To include recording presence or absence: poor urine flow, previous UTI or recurrent PUO, antenatal anomalies, FH of ureteric reflux or kidney disease, constipation, dysfunctional voiding, enlarged bladder, abdominal mass, evidence of spinal anomaly, poor growth , high blood pressure

2. Obtain urine for testing

Clean catch urines should be obtained from all children with unexplained fever greater than 38 deg C or symptoms or signs of UTI: vomiting, frequency, dysuria, poor feeding, failure to thrive, abdo pain, acute incontinence, malaise, offensive urine – Supply sterile galipot while waiting

Alternatives to clean catch such as bag urine, CSU and SPA should only be used if clean catch not possible. E.g. urgent full infection screen indicated in young child – SPA should always use ultrasound to confirm urine in bladder

3. Testing urine

Less than 3 years – send for urgent microscopy and culture

Over 3 years – Use dipstick to diagnose UTI

Managing results:

Microscopy less than 3 years:

Leucocytes positive / Leucocytesneg.
Bacturia positive / UTI / UTI
Bacturia negative / UTI if supportive signs / Not UTI

Dipstick – over 3 years

Leuc + nitr+ / Treat send for culture if previous infection or risk of serious illness
Leuc – nitr + / Treat send for culture
Leuc + nitr - / Send for culture treat only if good clinical evidence
Leuc – nitr - / Do not treat Do not send for culture unless recurrent

4. Treatment

Less than 3 months – treat as per childhood fever – full septic screen and iv antibiotics

Over three months and unwell –7- 10 day oral antibiotics – trimethoprim

If not tolerated or septicaemic then iv cefuroxime

Over three months,if bacturia /dysuria frequency alonewith no systemic features- cystitis- trimethoprim 3 days only)

5. Further Investigations:

Child < 6 months:USS within 6 weeks alone unless:

Atypical or recurrent:Urgent USS, MCUG as OPD,DMSA @ 4-6

months

6 month -3 years:no investigations unless:

Atypical – Urgent USS, DMSA @4-6 month

Recurrent – USS within 6 weeks, DMSA @4-6 month

Child > 3 years:No investigations unless:

Atypical - Urgent USS

Recurrent – USS within 6 weeks DMSA @ 4-6 months

Definitions:

Atypical : severely ill, poor urine flow, abdominal or bladder mass, raised creatanine, septicaemia, failure to respond to antibiotics within 48 hrs, infection with non E.coli organisms

Recurrent: one Pylonephritis plus any other UTI or three cystitis ( pylonephritis = bacturia with

fever or loin pain)

6. Prophylaxis – not covered in NICE guideline (trimethoprim 2 mg kg nocte)

Recurrent UTI – 6 weeks pending ultrasound, consider 3 months treatment if

2 infections in 3 months

Known antenatal renal tract dilatation – until resolved or 2 years

Proven renal scar – until 4 years

7. Follow up:

No follow up: if no investigations or if investigations are normal (letter to parents)

Recurrent UTI or with abnormal tests – follow up at 3 months – if scar need growth blood

pressure and proteinuria screening (unilateral small scar use judgement)