CLINICAL GUIDELINE FOR THE MANAGEMENT AND
INVESTIGATION OF URINARY TRACT INFECTION IN
CHILDREN.
1. Aim/Purpose of this Guideline
1.1. This guideline aims to give clear guidance on appropriate treatment and
investigations required for children with urinary tract infection. It applies to
medical and nursing staff caring for these children and their families.
2. The Guidance
2.1. The Prompt diagnosis and treatment of UTI is thought to be the most
effective available method of minimising renal damage in patients with a possible
or known underlying renal tract abnormality
There is no other proven effective prevention of on-going renal damage in
patients with vesico-ureteric reflux. Neither surgery nor prophylactic antibiotics
have been proven to be effective in preventing further UTIs or further renal
impairment
The important renal tract abnormalities to identify are those of obstruction: PUJ,
VUJ or posterior urethral valves, and those of major renal anomalies such as
dysplastic kidneys. If these are not seen on antenatal USS they will most
commonly present in the first few months of life. Investigations are therefore
targeted at these.
Features of an ‘atypical UTI’ – high fever, ‘seriously ill’, evidence of renal tract
obstruction, non-E-coli UTI – are more likely to be associated with an underlying
renal tract anomaly.
Recurrent UTIs / pyelonephritis should also raise suspicion of an underlying renal
anomaly
Main areas to note following changes in guidance are that routine prophylactic
antibiotics following a first UTI in an infant or child are no longer recommended,
and that follow-up investigations have been rationalised and are dependent on
whether an ‘atypical’ or ‘recurrent’ UTI has been diagnosed.
Clinical Guideline for the management and investigation of urinary tract infection in children.
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2.2. Step 1 – Identifying the child with a UTI
Consider UTI in children with the following features:
Age Group
Infants < 3
months
Infants and
children ≥3
months
Symptoms and Signs
Most common
 Least common
Fever
Poor feeding
Abdominal pain
Vomiting
Failure to thrive
Jaundice
Lethargy
Haematuria
Irritability
Offensive urine
Fever
Abdominal pain
Lethargy
Frequency
Loin tenderness
Irritability
Dysuria
Vomiting
Failure to thrive
Poor feeding
Haematuria
Dysfunctional voiding Offensive urine
Changes to
Cloudy urine
continence
Any child under the age of 5 years with a fever should have a urine test as should any
infant or child with a fever without an obvious focus.
In a baby under 6 months who is unwell with an upper UTI (pyelonephritis) a full sepsis
screen including LP should be considered as the infection could have seeded from the
blood.
2.3. Step 2 – Is this a Simple UTI or Upper UTI ( Pyelonephritis)
Bacteriuria and fever of ≥38C
Bacteriuria, loin pain/tenderness and
fever of less than 38ºC
Bacteriuria but no systemic features
Upper UTI
Upper UTI
Simple UTI
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2.4. Step 3 - Is this an ‘Atypical’ or ‘Recurrent’ UTI?
Atypical UTI
This aims to identify features of the UTI that might suggest an underlying renal tract
obstruction – such as vesicoureteric obstruction, pelvicoureteric obstruction and posterior
urethral valves. Please document any of these features under ‘atypical features’.
• “Seriously ill”
• Poor urine flow
• Abdominal or bladder mass
• Raised creatinine
• Septicaemia
• Failure to respond to treatment with suitable antibiotics within 48 hrs
• Infection with non-E-coli organisms
Definition of “Serious illness”
Appears ill to a healthcare professional
Age 0-3 months temperature >or = 38◦C
Age 3-6 month, temperature > or = 39◦C
Recurrent UTI
This aims to identify underlying renal tract abnormalities that predispose to recurrent UTIs
– specifically obstruction resulting in stasis of urine in the renal system. A full UTI history
should be documented in the notes.
•Two or more acute pyelonephritis/upper UTIs
•One upper UTI and one lower UTI
•Three lower UTIs
Relevant history and examination findings
In addition to your usual history and examination findings, please check for these findings
which may affect your further investigation and management:






Poor urine flow
History suggesting, or
confirmed, previous UTI
Recurrent fever of uncertain
origin
Antenatally-diagnosed renal
abnormality
Constipation
Dysfunctional voiding





Family history of vesicoureteric
reflux (VUR) or renal disease
(consider MCUG or MAG3
scan– see imaging section )
Enlarged bladder
Abdominal mass
Evidence of spinal lesion
High blood pressure
Clinical Guideline for the management and investigation of urinary tract infection in children.
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Step 4 – Collect an uncontaminated urine sample
A clean catch sample is the recommended method of urine collection.

Do not use pad, bag, cotton wool balls, gauze or sanitary towels as per the
‘Procedure for urine clean catch collection in infants and children’ RCHT Clinical
Guideline available on the Documents Library.
If other non-invasive methods are not possible:
 Use a catheter or suprapubic aspiration (SPA). These should be considered in
unwell babies requiring a sepsis screen and urgent antibiotics as it allows rapid
collection of urine.
If the child is seriously ill do not delay antibiotics.
2.5. Step 5 – Use the appropriate method for identifying infection in the
urine
Children younger than 3 years:
Urgent flow cytometry of a clean catch sample (urine dipstick testing is unreliable in this
age group)
Pyuria positive (White cell count >40) -
start antibiotics if clinically UTI
Pyuria negative -
not confirmed as UTI
Children 3 years or older:
First use urine dipstick test for leukocyte esterase and nitrites to diagnose UTI
If the dipstick is positive for both manage as a UTI and send urine for culture.
If it is positive for either one, send for microscopy and culture and be guided by the
microscopy result
If it is negative for both then only send if there is clinical suspicion of a UTI.
Clinical Guideline for the management and investigation of urinary tract infection in children.
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2.6. Step 6 – Treat the UTI with appropriate length and administration
method of antibiotics
Age < 3months
Manage upper and lower UTI with IV antibiotics.
1st line: Amoxicillin TDS and Gentamicin OD 5 days
If 4 weeks or younger 2nd line: Cefotaxime
If >4weeks and <3months 2nd line: Ceftriaxone
If 3 months or older with upper UTI (bacteriuria and fever ≥38°C or bacteriuria and
loin tenderness):
Treat with an oral antibiotic course for 7-10 days.
1st line: Trimethoprim 4mg/kg/day BD unless previous resistance.
If unable to tolerate oral antibiotics (vomiting, very unwell) use IV antibiotics for 2-4 days
followed by oral antibiotics for a total duration of 10 days.
1st line: Ceftriaxone
If 3 months or older with a simple UTI
Treat with oral antibiotics for 3 days
1st line: Trimethoprim 4mg/kg/day BD unless previous resistance.
If still unwell after 24-48 hours they should be re-assessed
If previous resistance to trimethoprim consider nitrofurantoin or cefradine depending on
previous sensitivities, this can be discussed with the microbiology department
DO:




Check urine sensitivities and change antibiotics as appropriate.
If an infant or child is receiving prophylactic medication and develops an infection
treat with a different antibiotic.
In any child who is still unwell after 24-48hrs send or re-send urine sample for
culture and sensitivities and review antibiotic choice.
Consider intramuscular treatment if parental treatment is required and IV treatment
is impossible.
DON’T
 Treat asymptomatic bacteriuria with antibiotics (usually found on re-checking of a
urine sample post UTI).
 Routinely use antibiotic prophylaxis after first-time UTI but consider after recurrent
UTI.
PLUS
 Address dysfunctional elimination syndromes (bladder instability) and constipation
which may contribute to UTIs.
 Ensure blood pressure measurement obtained and checked against normal range
for age and height.
Clinical Guideline for the management and investigation of urinary tract infection in children.
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2.7. Step 7 - Investigate for underlying renal abnormality as appropriate
Investigations:
Renal USS – to assess renal structure. Can also identify dilated ureters and bladder
function so can detect PUJ obstruction, VUJ obstruction and posterior urethral valves
DMSA scan– assesses comparative renal function. Identifies renal parenchymal defects
(secondary to scarring or dysplasia). Requires intravenous access and injection of
radioactive dye
MCUG – assesses urinary flow from bladder. Identifies vesicoureteric reflux and posterior
urethral valves. Requires urinary catheter insertion and injection of dye. Requires 3 days
antibiotic cover for catheter.
MAG3 scan – assesses comparative renal function and urinary flow from bladder.
Identifies renal scarring, reflux and obstruction. Requires an intravenous cannula for
injection of dye. Normally only carried out if child is 18months or older.
Children with ‘atypical’ and ‘recurrent’ UTIs (see previous definitions) are more likely to
have an underlying renal tract abnormality so are investigated for this more intensively.
Follow-up MCUG
If a follow-up MCUG is indicated antibiotic prophylaxis is required the day before, day of
and day after the procedure. This is because a urinary catheter is inserted which could
introduce infection. On discharge, please send home with a 3 day prescription of
trimethoprim 2mg/kg/dose once daily to be obtained prior to the procedure (unless
already on prophylaxis). A different antibiotic can be used if indicated. Please also give
the parents the MCUG advice sheet.
Writing the imaging form
Please put on each form:
1. Date of infection
2. ‘Simple UTI’, ‘Atypical UTI’ or ‘Recurrent UTI’
3. If ‘Atypical UTI’, list the atypical features
In the GP surgery
A simple, first-time UTI diagnosed between the age of 6 months and 7 years without
atypical or recurrent features can be investigated with a renal USS without need for
referral to a paediatrician. It is useful to check for a history of recurrent, unidentified fevers
as this could place the child in the ‘recurrent UTI’ group. Children with abnormal renal
USS findings can then be referred.
Clinical Guideline for the management and investigation of urinary tract infection in children.
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Imaging Schedules According to Age and Presentation
Imaging schedule for infants younger than 6 months
Test
Responds well Atypical UTI
to
treatment
within 48hrs
Ultrasound
during No
acute infection
Ultrasound within 6 Yes (if abnormal
weeks
consider
MCUG)
DMSA 4-6 months No
following the acute
infection
MCUG
No
Recurrent UTI
Yes
No
Yes
Yes
Imaging schedule for children older than 6 months but younger than 18 months
Responds well Atypical UTI
Recurrent UTI
Test
to
treatment
within 48 hours
Ultrasound
during No
Yes
No
the acute infection
Ultrasound within 6 Yes
No
Yes
weeks
DMSA 4-6 months No
Yes
Yes
after acute infection
MCUG
No*
No*
No*
*Consider MCUG if family history of VUR, dilatation on USS, poor urine flow, non-E-coli
infection
Imaging schedule for children 18 months to 7 years
Responds well Atypical UTI
Recurrent UTI
Test
to
treatment
within 48 hours
Ultrasound during No
Yes up to age 7 No
the acute infection
years
Ultrasound within 6 Yes up to age 7 No
Yes up to age
weeks
years
7 years
MAG3 4-6 months No
Yes up to age 3 Yes up to age
after
acute
years
3 years
infection
For all ages, if the infant or child has a subsequent UTI while awaiting DMSA or
MAG3, review timing of the scan and consider doing it sooner
Clinical Guideline for the management and investigation of urinary tract infection in children.
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2.8. Step 8 – Arrange appropriate follow-up
Give children and parents RCHT advice leaflet on UTI.
Emphasise importance of the need for treatment, of completing treatment and advice
about prevention and long-term management. Also mention the possibility of a UTI
recurring, and the importance of being vigilant and seeking prompt treatment from a
healthcare professional
No Routine Follow-Up
 If all imaging results are normal, a routine follow-up appointment is not required.
 Infants and children who are asymptomatic following an episode of UTI should not
routinely have their urine re-tested for infection
 Asymptomatic bacteriuria is not an indication for follow-up (usually obtained if
follow-up urine sample collected in asymptomatic patient)
Referral and Assessment
 Recurrent UTI or abnormal imaging results should be assessed by a paediatric
specialist
 Assessment of infants and children with renal parenchymal defects should include
height, weight, blood pressure and routine testing for proteinuria
 Infants and children with a minor, unilateral renal parenchymal defect do not need
long-term follow-up unless they have recurrent UTI or family history or lifestyle risk
factors for hypertension.
Long-term follow-up
 Infants and children who have bilateral renal abnormalities, impaired kidney
function, raised blood pressure and/or proteinuria should be reviewed by a
paediatric nephrologist to slow the progression of chronic kidney disease.
2.9. Urine results- Test stick interpretation
Age less than 3 years:
 Urine test stick is unreliable and if there is clinical suspicion of a UTI then
the sample should be sent for urgent flow cytometry and actioned as
below.
Age 3 years and above:
 Positive for leukocytes and nitrites: treat as UTI and send for culture.
 Positive for leukocytes or nitrites: send for urgent flow cytometry and treat
as below.
 Negative for leukocytes and nitrites: only send for culture if strong clinical
suspicion of UTI.
Clinical Guideline for the management and investigation of urinary tract infection in children.
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2.10.Flow Cytometry Definitions (same across all ages):
White Cell Count (WCC):
 Greater than 40 WBC/ml = definite pyuria
 Less than 40 WBC/ml = unlikely pyuria
 ‘Positive’ flow cytometry means that there is bacteruria (NB this could be
positive in a contaminated urine sample)
2.11.Flow Cytometry Interpretation (same across all ages):
Flow cytometry
results
WCC ≥40
WCC <40
Flow cytometry
positive
The infant or child
should be regarded
as having UTI
The infant or child
should be regarded
as having possible
UTI??
Flow cytometry
negative
Antibiotic treatment
should be started if
clinically UTI
The infant or child
should be regarded
as not having UTI
2.12.Culture Interpretation:
Beware multiple urine samples from the same patient on the system. Some may
have been collected before antibiotics and some after antibiotics, but the results
don't necessarily come back in the order they were sent it seems that the negative
results come through quicker (probably because antibiotic sensitivity testing has to
be done on positive cultures). This may lead to antibiotics being stopped mistakenly
based on a sample taken after antibiotics were started.
No growth:
-
WCC <40: Negative
WCC ≥40: Sterile pyuria
Pure growth:
- WCC <40: Possible UTI
- WCC ≥40: Definite UTI
Mixed growth:
- WCC ≥40: Assumed UTI. Antibiotics should have been started
during the acute admission therefore repeat will be unreliable.
- WCC <40: Unlikely UTI. Consider repeat as detailed below
Note there is a small chance of clinically significant pyuria with WCC <
40/ml, therefore:
Under 3 years: Possible UTI which would then require a repeat.
Age 3years and over:
a) If test stick was negative for leucocytes and nitrites: Negative
b) If test stick was positive for either: Possible UTI which would
then require a repeat.
Clinical Guideline for the management and investigation of urinary tract infection in children.
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2.13.Culture Actions:
A) Document and communicate actions as per Section 2.15
B) Actions as per table below:
Interpretation
Negative
or Unlikely UTI
Action
Check for other urine samples on the system
associated with the same admission:
- If no other samples, or all samples negative,
no further follow-up required.
- If other samples fall into any of the following
categories, action as below.
Sterile pyuria
1) Repeat urine culture indicated
2) Contact parents
3) Consider investigation if persistent on 2 or more
samples.
1) Repeat urine culture indicated
2) Contact parents
- If child remains unwell, treat as UTI pending
culture results of 2nd urine.
- If child well, repeat urine culture and do not
treat.
1)Check e-discharge
- If UTI already treated and appropriate
investigations have been arranged, no further
actions required.
- If not had appropriate treatment or
investigations: contact parents and GP to
arrange.
1) Contact parents.
2) If antibiotics not started, repeat urine and if child
remains unwell, treat as UTI pending 2nd culture
results.
3) If antibiotics already started, investigate as per
guideline.
Possible UTI
Definite UTI
Assumed UTI
2.14.Repeat urine samples:
If asking parents/GPs to repeat urine samples please remind them this needs to be
a CLEAN CATCH URINE (not bag or pad) as per the ‘Procedure for urine clean
catch collection in infants and children’ guideline on the Documents Library.
GP to organise repeat urine sample and chase the results (they can contact us for advice
if required).
Clinical Guideline for the management and investigation of urinary tract infection in children.
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2.15.Documentation and communication of actions, including
conversations with parents/GP:

Document any actions (e.g. any conversations with parents and the GP) on a
continuation sheet and then give this to the ward clerks to file. If the child has
already been discharged and the notes are unavailable.

Communicate actions as follows: Type a letter in Trust Letter Head Template
(found in Templates section of Documents Library.) Letter templates
specifically for UTI’s are available as examples in Appendix 3-6 of this
guideline. Then email to consultant and their secretary. The secretary can
then format and put it on maxims and include copy for parent.
3. Monitoring compliance and effectiveness
Element to be
monitored
Lead
Tool
Frequency
Reporting
arrangements
Acting on
recommendations
and Lead(s)
Change in
practice and
lessons to be
shared
Compliance with guideline
Audit lead
Audit, weekly safety audits, SIMS
Annually or before if required
Paediatric audit and guidelines meeting
Paediatric audit and guidelines meeting
Required changes to practice will be identified and actioned within
a specific time frame. A lead member of the team will be identified
to take each change forward where appropriate. Lessons will be
shared with all the relevant stakeholders
4. Equality and Diversity
4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service
Equality and Diversity statement.
4.2. Equality Impact Assessment
The Initial Equality Impact Assessment Screening Form is at Appendix 2.
Clinical Guideline for the management and investigation of urinary tract infection in children.
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Appendix 1. Governance Information
Document Title
Clinical Guideline for the management and
investigation of urinary tract infection in
children.
Date Issued/Approved:
February 2017
Date Valid From:
February 2017
Date Valid To:
February 2020
Directorate / Department responsible
(author/owner):
Dr.Chris Williams-paediatric consultant
Contact details:
01872 252463
Brief summary of contents
Clear guidance in the treatment and
investigation of urinary tract infections in
children.
Paediatrics
Children
Urinary
Tract
Infection
Treatment
RCHT

Suggested Keywords:
Target Audience
PCH
CFT
KCCG
Executive Director responsible for
Policy:
Executive Director
Date revised:
February 2017
This document replaces (exact title of
previous version):
General paediatrics-renal- management
and investigation of urinary tract infection.
Consultant microbiologist
Consultant radiologist
Paediatric consultants
Paediatric audit and guidelines meeting
Approval route (names of
committees)/consultation:
Divisional Manager confirming
approval processes
David Smith
Name and Post Title of additional
signatories
Not Required
Signature of Executive Director giving
approval
Publication Location (refer to Policy
on Policies – Approvals and
Ratification):
{Original Copy Signed}
Internet & Intranet
Clinical Guideline for the management and investigation of urinary tract infection in children.
Page 12 of 19
 Intranet Only
Document Library Folder/Sub Folder
Paediatrics
Links to key external standards
none
Related Documents:
NICE guidelines for UTI in children 2007
Training Need Identified?
No
Version Control Table
Date
Versio
n No
October
2009
V1.0
February
2014
February
2017
Summary of Changes
Changes Made by
(Name and Job Title)
Initial Issue
Dr.N.Westpaediatrics
V2.0
Review and re format
Dr.C.Williams-paediatric
consultant
Dr.K.Mallam paediatric
consultant and
Dr.C.Lea- results section
Tabitha Fergus- Deputy
ward manager-reformat
only
V3.0
Review , Urinary and Tract added to Keywords consultant
Dr.C.Williams-paediatric
All or part of this document can be released under the Freedom of Information
Act 2000
This document is to be retained for 10 years from the date of expiry.
This document is only valid on the day of printing
Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS Trust
Policy on Document Production. It should not be altered in any way without the
express permission of the author or their Line Manager.
Clinical Guideline for the management and investigation of urinary tract infection in children.
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Appendix 2. Initial Equality Impact Assessment Form
Name of the strategy / policy /proposal / service function to be assessed (hereafter referred to
as policy) (Provide brief description): Clinical Guideline for the management and investigation
of urinary tract infection in children.
Directorate and service area: Child
Is this a new or existing Policy? existing
Health
Name of individual completing
Telephone: 01872252800
assessment: T.Fergus
1. Policy Aim*
Clear guidance for the management and investigation of urinary tract
Who is the strategy /
infection in children.
policy / proposal /
service function
aimed at?
2. Policy Objectives*
Clear guidance for the management and investigation of urinary tract
infection in children.
3. Policy – intended
Outcomes*
Evidence based and standardised practice.
4. *How will you
measure the
outcome?
5. Who is intended to
benefit from the
policy?
6a) Is consultation
required with the
workforce, equality
groups, local interest
groups etc. around
this policy?
Audit, safety audits.
Children and families.
no
b) If yes, have these
*groups been
consulted?
C). Please list any
groups who have
been consulted about
this procedure.
7. The Impact
Please complete the following table.
Are there concerns that the policy could have differential impact on:
Equality Strands:
Age
Yes
No
x
Rationale for Assessment / Existing Evidence
Clinical Guideline for the management and investigation of urinary tract infection in children.
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Sex (male, female, trans-
X
gender / gender
reassignment)
Race / Ethnic
communities /groups
X
Disability -
X
learning
disability, physical
disability, sensory
impairment and
mental health
problems
Religion /
other beliefs
X
Marriage and civil
partnership
X
Pregnancy and maternity
X
Sexual Orientation,
x
Bisexual, Gay, heterosexual,
Lesbian
You will need to continue to a full Equality Impact Assessment if the following have been
highlighted:
 You have ticked “Yes” in any column above and
 No consultation or evidence of there being consultation- this excludes any policies
which have been identified as not requiring consultation. or
 Major service redesign or development
No
8. Please indicate if a full equality analysis is recommended.
Yes
x
9. If you are not recommending a Full Impact assessment please explain why.
No areas indicated.
Signature of policy developer / lead manager / director
T.Fergus
Names and signatures of
members carrying out the
Screening Assessment
Date of completion and submission
Feb 2017
1.
2.
Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead,
c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa,
Truro, Cornwall, TR1 3HD
A summary of the results will be published on the Trust’s web site.
Signed ____C.Williams ___________
Date ____Feb 2017____________
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