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NICE clinical guideline 54
The Department of Health asks NHS organisations to work towards implementing guidelines
Compliance with developmental standards will be monitored by the Healthcare Commission
Collecting urine and interpreting laboratory results is not easy Diagnosis is not always confirmed UTI in infants and children may have long-term sequelae
Management
antibiotic treatment
Imaging
Follow-up
Key recommendations
Symptoms and signs
Urine collection Urine testing History and examination Acute management Antibiotic prophylaxis Imaging tests
Assess the symptoms and signs Test urine when an infant or child presents with:
Younger than 3 months: fever, vomiting, lethargy, irritability, poor feeding, failure to thrive, abdominal pain, jaundice, haematuria, offensive urine 3 months or older and preverbal: fever, abdominal pain, loin tenderness, vomiting, poor feeding, lethargy, irritability, haematuria, offensive urine, failure to thrive
3 months or older and verbal: frequency, dysuria, dysfunctional voiding, changes to continence, abdominal pain, loin tenderness, fever, malaise, vomiting, haematuria, offensive or cloudy urine
Urine collection and testing: infants and children aged 3 months to 3 years
If the infant or child presents with specific urinary symptoms:
Urgent microscopy and culture is the preferred method for diagnosing UTI. After a urine sample is obtained, antibiotic treatment should be started. If urgent microscopy is not available, send a urine sample for microscopy and culture. If the infant or child presents with symptoms that are nonspecific to UTI: Urgent microscopy and culture is the preferred method for diagnosing UTI, but for infants and children with an intermediate risk of serious illness, when this is not available, dipstick testing for leucocytes and nitrite may be used.
Determine location
Acute Bacteriuria and fever of 38C or higher pyelonephritis/ upper urinary tract Bacteriuria, loin pain/tenderness and fever of less infection than 38C
Cystitis/lower urinary tract infection Bacteriuria and symptoms or signs of UTI that are not systemic
Treat with oral antibiotic, such as cephalosporin or co-amoxiclav, for 7-10 days
If oral antibiotics cannot be used, give parenteral antibiotic treatment in line with the NICE guideline Feverish illness in children (clinical guideline 47)
Antibiotic prophylaxis
Prophylactic antibiotics have been used on the assumption that they prevent further infections that may be associated with systemic illness and thus avoid subsequent renal damage. However, further evaluation is needed.
Antibiotic prophylaxis should not be routinely recommended following first-time 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 episodes of UTI with cystitis/lower urinary tract infection, or Three or more episodes of UTI with cystitis/lower urinary tract infection
Septicaemia
Failure to respond to treatment with suitable antibiotics within 48 hours Infection with non-E. coli organisms.
Imaging
Recommended imaging schedule for infants younger than 6 months
Test Responds well to treatment within 48 hours No Yes Atypical UTI Recurrent UTI
Yes No
Yes No
Yes
Yes
Yes
Yes
Imaging
Recommended imaging schedule for infants and children 6 months and older but younger than 3 years
Test Responds well to Atypical UTI treatment within 48 hours No No No Yes No Yes Recurrent UTI No Yes Yes
Ultrasound during the acute infection Ultrasound within 6 weeks DMSA 46 months following the acute infection MCUG
No
No
No
Imaging
Recommended imaging schedule for children 3 years and older
Test Responds well to treatment within 48 hours No No No Atypical UTI Yes No No Recurrent UTI No Yes Yes
Ultrasound during the acute infection Ultrasound within 6 weeks DMSA 4 6 months following the acute infection MCUG
No
No
No
Implementation advice
Feedback to NICE suggests that there are likely to be four key areas for successful implementation:
Diagnosis Training and equipment
Communication
Research and audit
Total net cost of implementing the urinary tract infection in children guideline
0.8