Urinary Tract Infection In Children Management And Referral
Transcript of Urinary Tract Infection In Children Management And Referral
Version 4.3 Jan 19 - Review March 2022 Author(s) R Bragonier Consultant General Paediatrician, J Dudley Consultant Paediatric Nephrologist Page 1 of 10
Clinical Guideline
URINARY TRACT INFECTION (UTI) IN CHILDREN - MANAGEMENT AND REFERRAL
SETTING Bristol Royal Hospital for Children (BRHC)
FOR STAFF Medical and nursing
PATIENTS Children in BRHC with suspected or confirmed UTI
Background: This guidance is adapted from National Institute of Care Excellence (NICE) guidance CG54 (2007, updated 2017)
Important practice points
• In suspected UTI, prompt antibiotic treatment after obtaining urine culture will reduce riskof subsequent renal scarring
• Many children no longer need paediatric referral following UTI – see Algorithms• Prophylactic antibiotics are no longer routinely indicated following first UTI• Less extensive imaging is required in children >6 months than previously – see Algorithms• Search for and treat underlying constipation
Suspect diagnosis Age-related symptoms –Section A
Collect urine Preferred collection methods - Section B
Test/send sample Predictive value of stick test - Section C
Treat appropriately Cystitis or Pyelonephritis? - Section D
Acute referral criteria & antibiotics – Section E
Scan, refer and follow-up as needed Algorithms for scanning/referral - Section F
Follow-up - Section G
Next review date March 2022
Version 4.3 Jan 19 - Review March 2022 Author(s) R Bragonier Consultant General Paediatrician, J Dudley Consultant Paediatric Nephrologist Page 2 of 10
Section A – Symptoms and signs by age
Age Most common Least common
< 3months
Unexplained fever
Vomiting
Lethargy
Irritability
Poor feeding
Faltering growth
Abdominal pain
Jaundice
Haematuria
Offensive urine
Preverbal
(infants & toddlers) Fever
Abdominal pain
Loin tenderness
Vomiting
Poor feeding
Lethargy
Irritability
Haematuria
Offensive urine
Faltering growth
Verbal
(children)
Frequency
Dysuria
Dysfunctional voiding
Deterioration in continence
Abdominal pain
Loin tenderness
Fever
Malaise
Vomiting
Haematuria
Offensive or cloudy urine
Infants, children and young people with a urinary tract infection should have the following risk factors for urinary tract infection and serious underlying pathology recorded as part of their history and examination:
poor urine flow
history suggesting previous UTI or confirmed previous UTI
recurrent fever of uncertain origin
antenatally-diagnosed renal abnormality
family history of vesicoureteric reflux (VUR) or renal disease
constipation
dysfunctional voiding
enlarged bladder
abdominal mass
evidence of spinal lesion
poor growth
high blood pressure
Section B – Urine collection
Test if:
Unexplained fever >38C, in any age child, within 24 hours of onset
Symptoms/signs suggesting UTI (above)
Feverish illness due to apparent other cause, but not improving
Next review date March 2022
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Nitrite +ve Nitrite -ve
Leukocyte esterase +ve UTI highly likely, send for MC&S, start treatment
UTI likely, send for MC&S, start treatment
Leukocyte esterase -ve UTI likely if freshly voided sample, send for MC&S, start treatment
No UTI, do not send for MC&S unless strong suspicion of UTI
Pyruria No pyuria
Bacteriuria UTI, start treatment Regard as UTI, start treatment
No Bacteriuria Treat if clinically has UTI No UTI
Collect by:
'Clean catch' recommended and best practice. Bag specimens strongly discouraged (highincidence of contamination).
If 'clean catch' not possible, use special collection pads (not cotton wool balls, sanitary towels,gauze).e.g. 'Uricol' Newcastle Urine Collection kits.
If neither possible, consider catheterisation (CSU), or supra-pubic aspiration (SPA), ideally underultrasound guidance, in hospital.
If child very unwell, do not delay antibiotics while awaiting specimen.
Sample storage:
Plain container, if can be cultured in lab within 4 hours
Otherwise, refrigerate sample or use Boric acid container (must be over half full)
Section C – Urine testing
Stick testing for nitrites and leukocyte esterase is helpful in excluding UTI and for predictingpositive culture in children over 3 months. Interpretation of stick test is age-dependent (see tablebelow)
But remember stick testing unreliable <3 months old (normal frequent passage of urinedoesn't allow time for nitrite formation). NICE suggests referral to secondary care if UTIsuspected under 3 months.
Use clinical criteria for decision-making in cases where urine stick testing does not support clinicalfindings
Predictive value of dipstick and microscopy:
DIPSTICK (3months – 3years)
DIPSTICK (over 3 years) Nitrite +ve Nitrite -ve
Leukocyte esterase +ve UTI highly likely, send for MC&S, start treatment
May be due to infection elsewhere, send for MC&S, do not start treatment unless strong clinical suspicion of UTI
Leukocyte esterase -ve UTI likely if freshly voided sample, send for MC&S, start treatment
No UTI, do not send for MC&S unless strong suspicion of UTI
MICROSCOPY (all ages)
Next review date March 2022
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Indications for sending sample for MC&S:
Suspected pyelonephritis (upper tract infection)
Patient very unwell
All cases <3months where UTI is suspected (remember sticks unreliable <3months)
Nitrite and/or Leukocyte esterase positive on stick test (as in tables above)
Recurrent UTIs
Suspected UTI unresponsive to treatment after 24 - 48 hours
Clinical symptoms strongly suggest UTI but stick test doesn't correlate
Section D - Pyelonephritis (upper tract infection) or Cystitis (lower tract)?
Acute pyelonephritis
Cystitis
Bacteriuria/+ve stick test and fever >38C
Bacteriuria/+ve stick test plus loin pain/tenderness, irrespective of fever
Bacteriuria/+ve stick test but fever <38C and no systemic symptoms (e.g. vomiting, loin pain/tenderness)
Section E – Treatment Please refer to the BRHC empirical medical antibiotic guidelines.
Do:
1. Change to new antibiotic if patient already taking antibiotic prophylaxis (revert to usual prophylaxis once UTI cleared)
2. Prevent further UTIs by: a. Treating any coexisting constipation b. Advising increase fluid intake c. Discouraging delayed bladder voiding
3. Give families of children who have had confirmed UTIs information about how to recognise re- infection (section A) and to seek medical advice straight away.
Don't: Treat asymptomatic bacteriuria
Commence antibiotic prophylaxis after single UTI (consider if recurrent)
Next review date March 2022
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Section F – Scanning and referral
For definitions of 'Atypical' and 'Recurrent' UTIs, and abbreviations used in these algorithms, see below.
'Atypical' UTI
Any of:
'Seriously ill' with UTI
Poor urine flow
Non-response to first 48 hours treatment
Non E coli infection
Septicaemia
Abdominal/bladder mass
Raised Creatinine
'Recurrent' UTI
2 or more 'upper tract' (pyelonephritis) UTIs
1 'upper tract' (pyelonephritis) and 1 'lower tract' (cystitis) UTI
3 or more lower tract (cystitis) UTIs
U/S
Renal tract ultrasound
Can be requested from:
Bristol Royal Hospital for Children (North Bristol GPs can arrange UHB ICE ordering access via their practice managers)
Weston General Hospital
If continent, also request 'bladder emptying' on form
MCUG
Micturating cysto-urethrogram (for detecting VUR and posterior urethral valves)
MCUG antibiotic prophylaxis
Trimethoprim 4mg/kg/dose BD for 3 days, with MCUG on 2nd
day
DMSA
Dimercaptosuccinic acid or static renal scan (for detecting relative function and scarring)
VUR
Vesico-ureteric reflux
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Imaging requirements: Children 0 - 6 months
Responds well to treatment within 48 hours
‘Atypical’ ‘Recurrent’
U/S within 6 weeks U/S during acute episode
Normal Abnormal Refer to General Paediatrics
No follow-up
MCUG (with covering antibiotic prophylaxis)
DMSA 4 – 6 months after (most recent) UTI
Next review date March 2022
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Imaging requirements: Children 6 months - 3 years
Responds well to treatment within
48 hours
'Atypical' 'Recurrent'
Non E coli UTI, responding within 48 hours, with no other 'atypical' features
No investigation or follow-up
U/S during acute episode
Refer to General Paediatrics
U/S within 6 weeks
Refer to General
Paediatrics
DMSA 4 – 6 months after (most recent) UTI
Consider MCUG (with covering antibiotic prophylaxis) if any of: dilatation on U/S, poor urine stream, non E coli
UTI, family history of VUR
Next review date March 2022
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Imaging requirements: Children over 3 years
Responds well to treatment within
48 hours
'Atypical' 'Recurrent'
Non E coli UTI, responding
within 48 hours, with no other atypical features
U/S during acute episode, specifically requesting
'bladder emptying' assessment as well
U/S within 6 weeks, specifically requesting
'bladder emptying' assessment as well
U/S normal U/S abnormal
No other
investigation or follow-up
Refer to General Paediatrics
DMSA 4 – 6 months after (most recent) UTI
Next review date March 2022
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Section G – Follow-up (all ages)
No follow-up required if:
No imaging tests performed
Normal imaging (unless recurrent UTIs - below)
Follow-up if:
Recurrent UTIs, even if normal imaging
Abnormal imaging
Impaired renal function
Persistent proteinuria
Suggested follow-up plan
Monitor, at least annually:
Height
Weight
Blood pressure
Proteinuria
RELATED DOCUMENTS
NICE CG54 http://publications.nice.org.uk/urinary-tract-infection-in-children- cg54 NICE QS36 http://guidance.nice.org.uk/QS36 BRHC empirical medical antibiotic guidelines
AUTHORISING Paediatric Medicine Governance Group
BODY
SAFETY
QUERIES
Next review date March 2022