Urinary tract infection

  • PIC logo
  • See also

    Febrile child
    Sepsis
    SPA
    Urinary Tests

    Key Points

    1. Signs and symptoms of urinary tract infection (UTI) can be non-specific in young children.
    2. Collecting urine to exclude UTI is not required if there is another clear focus of fever and the child is not unwell.
    3. Urinary dipstick is a useful screening test, but a positive urine culture with pyuria confirms the diagnosis.
    4. Oral antibiotics are appropriate for most children with UTI. Children who are seriously unwell and most infants under 3 months usually require IV antibiotics.
    5. Seriously unwell children, those with renal impairment, and boys <3 months of age should have a renal ultrasound prior to discharge to exclude renal tract obstruction.

    Background

    • Signs and symptoms of UTI can be non-specific, and overlap with common viral illnesses, especially in younger children
    • A urine sample is required to diagnose or exclude UTI where clinically suspected
    • Consider UTI if fever without focus persists after 48 hours in young children

    Assessment

    History

    • Infants and pre-verbal children often present with non-specific symptoms such as fever, vomiting, poor feeding, lethargy and irritability
    • Older children may present with more typical symptoms such as dysuria, urinary frequency, lower abdominal and loin pain
    • Ask about previous UTI

    Examination

    • Examination may be normal in UTI other than the presence of fever
    • Lower abdominal or loin tenderness may be present
    • Non-specific findings include dehydration and lethargy  

    Assessment of severity

    • Clinical distinction between lower and upper UTI can be difficult, especially in younger children
    • Cystitis is suggested by features such as dysuria, frequency, urgency and lower abdominal discomfort
    • Pyelonephritis is suggested by systemic features such as fever, malaise, vomiting and loin tenderness

    Management

    Investigation

    Children with suspected UTI should have a urine sample collected; dipstick and microscopy screening can guide initial management. Check culture results after 24hrs to confirm or adjust management as appropriate.

    Urine samples should be collected prior to starting antibiotics (unless the child is seriously unwell and requires immediate IV therapy)

    • Older children able to void on request can provide a midstream urine sample
    • For younger pre-continent children, a clean catch is often suitable. Catheter or SPA may be required for seriously unwell infants.

    Urine Collection:

    • The perineal/genital area should be cleaned with saline-soaked gauze for 10 seconds before collecting midstream or clean catch urine.

    • Midstream urine (MSU): preferred method for toilet-trained children who can void on request – contamination rate 25%

    • Clean catch: appropriate for pre-continent children who cannot void on request, but are not seriously unwell (yield may be improved by gently rubbing child’s suprapubic area with gauze soaked in cold fluid, see urine tests) - contamination rate 25%

    • Suprapubic aspirate (see SPA): gold standard – contamination rate 1%

    • In/out catheter: useful if there is little urine in the bladder, such as after failed clean catch or SPA (discard first few drops of urine if possible to reduce contamination) – contamination rate 10%

    • Bag urine: not recommended for culture due to high false positive rates – contamination rate 50%

    Urine dipstick

    • Urine dipstick is a useful screening test to guide initial management
    • The presence of leucocytes and nitrites is suggestive of a UTI. See notes
    • Dipstick results are less reliable in neonates and young infants, particularly due to false negatives

    Urine Microscopy and Culture

    • Laboratory microscopy can complement dipstick results to guide initial management 
    • Bacteria and leucocytes on microscopy are suggestive of UTI. See notes
    • Epithelial cells (squames) suggest skin contamination and a poorly collected sample. Consider recollection
    • A positive culture with sufficient growth and pyuria confirms UTI
    • Growth of a single organism at >108 CFU/litre (>105CFU/ml) from any collection method suggests infection
    • Growth of a single organism at lower counts of 106-8 CFU/litre (>103-5CFU/ml) from catheter or SPA urine suggests infection, and from clean catch or MSU may indicate early infection
    • Growth of any amount from SPA suggests infection

    Other investigations

    • Check renal function and consider renal ultrasound if the child is seriously unwell, or not responding to appropriate therapy after 48hrs
    • Consider blood culture and lumbar puncture for unwell infants less than 4 weeks old, or if sepsis or meningitis is suspected at any age

    Treatment

    • Oral antibiotics are usually appropriate
    • Any child who is seriously unwell, and most infants under 3 months, should be admitted for initial IV antibiotics
    • 3-7 day course for children with cystitis
    • 7-10 day course for children with pyelonephritis

    Oral treatment

    Trimethoprim 4mg/kg BD (max 150mg) (only tablets generally available)

    or

    Trimethoprim/sulfamethoxazole (8mg/40mg per ml) 0.5ml/kg (max 20ml) BD (should be avoided in infants < 6 weeks old)

    or

    Cephalexin 25mg/kg (max 500mg) tds

    IV treatment

    • Do not delay antibiotic therapy for a child who is seriously unwell, even if a urine sample has not been obtained
    • Recommended empiric IV antibiotics: gentamicin + benzylpenicillin. See Antibiotic Guideline
      • check gentamicin levels and renal function before third dose if continuing gentamicin beyond 48 hrs
    • Switch to oral antibiotics when clinically improved and/or as soon as tolerating oral antibiotics

    Follow up

    • Seriously unwell children, those with renal impairment, and boys <3 months of age should have a renal ultrasound prior to discharge
    • Other children do not require an ultrasound for a first UTI; a non-urgent renal ultrasound should be arranged for children who have recurrent UTIs
    • Routine antibiotic prophylaxis after simple UTI is not required
    • Specialist follow-up should be arranged for children with recurrent UTI or known renal anomalies

    Consider consultation with local paediatric team when:

    • Child under 6 months of age
    • Child with known renal tract anomalies or not responding to initial therapy
    • Any child who is seriously unwell.

    Consider transfer when:

    Any child requiring care beyond the level of comfort of the treating hospital

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services.

    Consider discharge when:

    Tolerating oral fluids and antibiotics

    Parent information

    Kids Health Info

    Urinary tract infection  

    Urine Tests 

    New South Wales Children's Hospitals Network

    Urinary tract infection in children

    Queensland Children's Health

    Urinary tract infection 

    How to collect a clean urine specimen


     Information specific to RCH
    • Pharmacy will only make trimethoprim suspension for patients aged less than 6 weeks or patients with a contraindication to trimethoprim/sulfamethoxazole
    • Children with UTI are usually admitted under the General Paediatric unit
    • Consider Hospital In The Home if the child requires IV antibiotics but is well enough to be at home

    Additional notes

    Interpreting urine test results:

    • Blood and protein are not reliable markers of UTI
    • Nitrites are not produced by all urinary organisms, so the absence of nitrites on dipstick does not exclude UTI
    • Pyuria (leucocytes) can occur with other febrile illnesses, so pyuria alone on dipstick/microscopy does not confirm UTI
    • Pyuria may be absent in early infection or very young children
    • Pyuria and bacteria seen on microscopy are suggestive of UTI, but a positive culture is required to confirm the diagnosis
    • Pure growth at low colony counts (CFU) may indicate early infection. Consider sample recollection or empiric treatment if the child remains unwell


    Last updated July, 2019

  • Reference List

    1. Brandstrom P, Jodal U, Sillen U, et al. The Swedish reflux trial: review of a randomized, controlled trial in children with dilating vesicoureteral reflux. J Pediatr Urol 2011;7(6):594-600. doi: 10.1016/j.jpurol.2011.05.006 [published Online First: 2011/08/03]
    2. Cyriac J, Holden K, Tullus K. How to use... urine dipsticks. Arch Dis Child Educ Pract Ed 2016 doi: 10.1136/archdischild-2015-309083 [published Online First: 2016/11/12]
    3. Desai DJ, Gilbert B, McBride CA. Paediatric urinary tract infections: Diagnosis and treatment. Australian family physician 2016;45(8):558-63. [published Online First: 2016/09/10]
    4. Fitzgerald A, Mori R, Lakhanpaul M, et al. Antibiotics for treating lower urinary tract infection in children. The Cochrane database of systematic reviews 2012(8):Cd006857. doi: 10.1002/14651858.CD006857.pub2 [published Online First: 2012/08/17]
    5. Hoberman A, Greenfield SP, Mattoo TK, et al. Antimicrobial prophylaxis for children with vesicoureteral reflux. The New England journal of medicine 2014;370(25):2367-76. doi: 10.1056/NEJMoa1401811 [published Online First: 2014/05/06]
    6. Hoberman A, Wald ER. Urinary tract infections in young febrile children. The Pediatric infectious disease journal 1997;16(1):11-7. [published Online First: 1997/01/01]
    7. McMullan BJ, Andresen D, Blyth CC, et al. Antibiotic duration and timing of the switch from intravenous to oral route for bacterial infections in children: systematic review and guidelines. The Lancet Infectious Diseases. 2016 (8): e139-152.
    8. McTaggart S, Danchin M, Ditchfield M, et al. KHA-CARI guideline: Diagnosis and treatment of urinary tract infection in children. Nephrology (Carlton) 2015;20(2):55-60. doi: 10.1111/nep.12349 [published Online First: 2014/10/14]
    9. Ochoa Sangrador C, Pascual Terrazas A. [Systematic review of the validity of urine cultures collected by sterile perineal bags]. Anales de pediatria (Barcelona, Spain : 2003) 2016;84(2):97-105. doi: 10.1016/j.anpedi.2015.04.003 [published Online First: 2015/05/27]
    10. Ramage IJ, Chapman JP, Hollman AS, et al. Accuracy of clean-catch urine collection in infancy. The Journal of pediatrics 1999;135(6):765-7. [published Online First: 1999/12/10]
    11. Reaffirmation of AAP Clinical Practice Guideline: The Diagnosis and Management of the Initial Urinary Tract Infection in Febrile Infants and Young Children 2-24 Months of Age. Pediatrics2016;138(6) doi: 10.1542/peds.2016-3026 [published Online First: 2016/12/13]
    12. Roberts KB. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics 2011;128(3):595-610. doi: 10.1542/peds.2011-1330 [published Online First: 2011/08/30]
    13. Robinson JL, Finlay JC, Lang ME, et al. Urinary tract infections in infants and children: Diagnosis and management. Paediatrics & child health 2014;19(6):315-25.
    14. Shaikh N, Morone NE, Bost JE, et al. Prevalence of urinary tract infection in childhood: a meta-analysis. The Pediatric infectious disease journal 2008;27(4):302-8. doi: 10.1097/INF.0b013e31815e4122 [published Online First: 2008/03/05]
    15. Shaikh N, Mattoo TK, Keren R, et al. Early Antibiotic Treatment for Pediatric Febrile Urinary Tract Infection and Renal Scarring. JAMA Pediatr 2016;170(9):848-54. doi: 10.1001/jamapediatrics.2016.1181 [published Online First: 2016/07/28]
    16. Stein R, Dogan HS, Hoebeke P, et al. Urinary tract infections in children: EAU/ESPU guidelines. Eur Urol 2015;67(3):546-58. doi: 10.1016/j.eururo.2014.11.007 [published Online First: 2014/12/06]
    17. Strohmeier Y, Hodson EM, Willis NS, et al. Antibiotics for acute pyelonephritis in children. The Cochrane database of systematic reviews 2014(7):Cd003772. doi: 10.1002/14651858.CD003772.pub4 [published Online First: 2014/07/30]
    18. Tullus K. A review of guidelines for urinary tract infections in children younger than 2 years. Pediatric annals 2013;42(3):52-6. doi: 10.3928/00904481-20130222-10 [published Online First: 2013/03/06]
    19. Urinary tract infection in children and young people, NICE Quality Standard 36: National Institute for Health and Care Excellence; 2013 [Available from: https://www.nice.org.uk/guidance/qs36/resources/urinary-tract-infection-in-children-and-young-people-pdf-2098609602757 accessed 24th August 2017.
    20. Urinary tract infection in children: diagnosis, treatment and long-term management London, England: National Institute for Health and Clinical Excellence; 2007 [Available from: http://www.nice.org.uk/nicemedia/live/11819/36032/36032.pdf accessed May 4 2012.
    21. Williams G, Craig JC. Long-term antibiotics for preventing recurrent urinary tract infection in children. The Cochrane database of systematic reviews 2011(3):Cd001534. doi: 10.1002/14651858.CD001534.pub3 [published Online First: 2011/03/18]