CAEC Registration Identifier: 1110 Sheffield Children’s (NHS) Foundation Trust

Urinary Tract Infection (UTI)

Urinary Tract Infection

(UTI)

Reference: 1110
Written by: Lauren Tunstall, Grace Ehidiamhen
Peer reviewer: Judith Gilchrist
Approved: April 2020
Review Due: Feb 2023

Purpose
To guide the diagnosis and management of UTI

Intended Audience
Clinicians involved in the management of UTI

Author: Lauren Tunstall, ST4 and Grace Ehidiamhen, Consultant. Review date: Feb 2023
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 CAEC Registration Identifier: 1110 Sheffield Children’s (NHS) Foundation Trust
Urinary Tract Infection (UTI)

Table of Contents
1. Introduction
2. Intended Audience
3. Guideline content
1) Definition of urinary tract infection
2) Clinical assessment
3) Diagnosis
4) Acute treatment
5) Additional investigations
6) Use of prophylactic antibiotics/prevention of recurrence
7) Follow up
4. References
5. Appendix
1) Technique for suprapubic aspiration of urine
2) Information about imaging investigations

1. Introduction

Diagnosing urinary tract infection (UTI) in young children and infants can be difficult as
presentation is often with non-specific signs such as fever, irritability and vomiting. However,
accurate diagnosis and prompt treatment is important to reduce the risk of acute deterioration
and long term renal damage.
Whilst many children presenting with UTIs make a full recovery after appropriate treatment, there
is a subset of patients in whom infections may be associated with progressive loss of renal
function, or in whom there is an underlying congenital abnormality. A strategy to identify and
investigate high risk groups is therefore necessary.
This guideline is in concordance with NICE guidelines except where specified.

2. Intended Audience
Clinicians involved in the management of UTI.

3. Guideline Content

3.1 Definition of UTI

A UTI is a combination of clinical features plus significant growth of a single bacteria in the urine
(105 organisms /ml) on a clean catch urine (CCU) or mid-stream urine (MSU).

Every urine culture must be interpreted in the clinical context, and this is explored more in the
Diagnosis section of this guideline.

Author: Lauren Tunstall, ST4 and Grace Ehidiamhen, Consultant. Review date: Feb 2023
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Urinary Tract Infection (UTI)

3.2 Clinical assessment

The table below summarises the most typical presentations of patients with UTI. Investigation
should be considered for all patients with these signs and symptoms.

Patient group Most common → Least common

presenting features presenting features

Infants <3 months Fever Poor feeding Abdominal pain

vomiting Failure to thrive Jaundice
lethargy Haematuria
irritability Offensive urine

Preverbal child >3 Fever Abdominal pain Lethargy

months Loin tenderness Irritability
Vomiting Haematuria
Poor feeding Offensive urine
Failure to thrive

Verbal child >3 Frequency Dysfunctional Fever

years Dysuria voiding Malaise
Changes to Vomiting
continence Haematuria
Abdominal pain Offensive urine
Loin tenderness Cloudy urine

NOTE: GI symptoms including diarrhoea can be an associated symptom and the possibility of
UTI should not be dismissed due to its presence. Do not simply dismiss bacterial growth in urine
as contamination when there is diarrhoea.
- Important aspects of history to record presence/absence of:
- FH vesicoureteric reflux or renal disease
- Any antenatal urinary tract abnormality
- Any previous UTI
- Recurrent fever of uncertain origin
- Poor urine flow or dysfunctional voiding
- Constipation

- Important aspects of examination are:

- faecal loading
- high blood pressure
- height, weight and corresponding centiles
- abdominal mass or enlarged bladder
- evidence of spinal lesion (inspection of spine, lower limb neurology)

Upper tract UTI/pyelonephritis presents principally with fever at any age. In younger children
there may also features indicative of systemic illness, and in older children, loin
pain/tenderness. Therefore any infant with UTI and fever or systemic symptoms should be
treated as pyelonephritis and so should older children with UTI and loin pain/tenderness.
Routine use of USS to determine site of infection is not recommended.
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Urinary Tract Infection (UTI)

Assess risk of serious illness in accordance with recommendations in the “Fever of Unknown
Origin” guideline.

3.3 Diagnosis
A urine sample should be tested for the following patients:
- Unexplained fever - test urine within 24 hours
- Signs and symptoms of UTI
- Infant <3 months with fever >38 degrees / infant or child with a high risk of serious illness
(Fever of Unknown Origin Guideline)
- A patient with an alternative sign of infection who remains unwell
- A patient with fever with known urinary tract abnormality
NOTE: It is highly preferable that a urine sample is obtained, but in patients with a high risk of
serious illness, treatment should not be delayed if a sample is unobtainable.
A clean catch urine is the recommended method of sample collection.
When this is not possible, a catheter sample or suprapubic aspirate should be obtained.
NOTE – Before suprapubic aspiration is attempted, ultrasound guidance should be used to
demonstrate the presence of urine in the bladder.
A summary of the technique for suprapubic aspiration of urine is included in the appendix of this
guideline.

Urine dipstick testing

Should be performed for all patients with suspected UTI. A guide to interpretation of urine
dipstick results is summarised here:

● Patients <3 months – All need MC+S

● Patients 3 months - 3 years

LE positive Nitrite positive

Treat as UTI and send sample for MC+S

LE negative Nitrite positive

LE positive Nitrite negative

LE negative Nitrite negative Not UTI.

MC+S only indicated if signs and symptoms

● Patients >3years
Urine dipstick can be used to diagnose or exclude UTI alongside clinical assessment in patients
as follows:

Author: Lauren Tunstall, ST4 and Grace Ehidiamhen, Consultant. Review date: Feb 2023
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Urinary Tract Infection (UTI)

LE positive Nitrite positive UTI

LE negative Nitrite positive UTI - send for MC+S

(if fresh sample)

LE positive Nitrite negative Send for MC+S

Only treat for UTI if clinical symptoms as LE may indicate
infection outside of urinary tract

LE negative Nitrite negative Not UTI.

MC+S only indicated if strong clinical suspicion

Urine microscopy and culture (specify method of collection)

Indicated for:
- anyone suspected to have upper UTI/pyelonephritis
- infants and children with intermediate/high risk of serious illness
- infants <3 months with fever
- anyone with positive LE or nitrite
- anyone with recurrent UTI
- anyone with infection not responding to treatment within 24 - 48 hours (if sample not sent
initially)
- when clinical symptoms and urine dipstick results do not correlate
-
Results:

The relationship between qualitative and quantitative cell counts

in urine samples (applies to both WBCs and RBCs):

Nil <1 x 106/l

+/- 1-10 x 106/l
+ 10-40 x 106/l
++ 40-100 x 106/l
+++ 100-200 x 106/l
 Single organism growth of 105 per ml is associated with UTI

 Lower levels of bacterial growth can also represent UTI in the presence of suggestive
symptoms and clinical judgement should be used to assess the significance of this.

 Pyuria in the absence of bacterial growth should be interpreted in light of clinical

symptoms and timing of sample relative to antibiotic administration.

 Asymptomatic bacteriuria is defined as growth of bacteria at a significant

concentration of 10⁵ units/ml with no symptoms of UTI. It should not be treated with
antibiotics.

 Any bacterial growth in a suprapubic aspirate is considered significant.

Author: Lauren Tunstall, ST4 and Grace Ehidiamhen, Consultant. Review date: Feb 2023
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Urinary Tract Infection (UTI)

3.4 Acute treatment

Assess risk of serious illness in line with 3.15 FEBRILE CHILD UNDER 5 YEARS
WITHOUT A FOCUS and 3.16 Recognition and Treatment of Sepsis. Guidelines

● Infant <3 month: blood culture and CSF culture

Intravenous antibiotics in line with trust guideline
For confirmed UTI – minimum 7 days antibiotics

● >3 months and likely to have pyelonephritis:

- Total 7 day course of antibiotics

- Locally trimethoprim is still acceptable as first line. Alternatives are cefalexin or co-
amoxiclav. Take account of prior microbiology results in children who have had previous
UTI.

- If no improvement after 24-48 hours of antibiotic treatment, strongly consider use of IV

antibiotics, according to urine culture result, sensitivities and clinical situation. Also
consider the possibility of alternative diagnosis.

- If oral antibiotics are not appropriate initially for example due to vomiting, clinical concerns
of septicaemia and awaiting CSF/blood culture results, use intravenous antibiotics
according to SCH antibiotic guideline. It is reasonable to switch to oral antibiotics after 2-
4 days to complete 7 day course, depending on clinical progress and results.

● >3 months and likely to have lower tract UTI

- Treat with oral antibiotics for 3 days Trimethoprim is acceptable as first line
- If still unwell after 24-48 hours of antibiotic therapy, adjust treatment according to culture
result, or consider intravenous antibiotics if has become systemically unwell.
Alternatively, if urine culture negative, consider alternative diagnosis.

● Infant or child on prophylactic antibiotics

- Give an alternative antibiotic, NOT treatment dose of the prophylactic agent. If UTI
develops on prophylactic antibiotics, the infecting organism is likely resistant to that
agent.

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Urinary Tract Infection (UTI)

3.5 Additional investigations

These are indicated in patients at high risk of either renal scarring, or underlying congenital
abnormality which may predispose to UTIs and require specific management.
The patients most at risk are:
- those with severe systemic illness
- those with recurrent symptomatic UTIs
- infants <6 months of age
Consider the following definitions in planning further investigation of individual patients.
Atypical UTI:
- those who are seriously ill and have suspected/confirmed septicaemia
- poor urine flow
- abdominal or bladder mass
- raised creatinine
- failure to respond to treatment with suitable antibiotics within 48 hours
- infection with non-E.coli organisms
Recurrent UTI:
This is more concerning, especially recurrent upper tract UTI. It includes any one of the
following:

● ≥2 upper tract UTIs

● 1 episode of upper tract UTI, plus ≥ 1 episode of lower tract UTI
● ≥3 episodes of lower tract UTI

Investigation of children <6 months

Test Responds well to Atypical UTI Recurrent UTI

treatment within 48
hours

Ultrasound during No Yesª Yes

acute infection

Ultrasound within 6 Yesᵇ No No

weeks

DMSA 4-6 months No Yes Yes

following acute
infection

MCUG No Yes Yes

ª If abnormal, consider MCUG

ᵇ In an infant or child with a non-E.coli UTI, responding well to antibiotics and with
no other features of atypical infection, the USS can be requested on a non-urgent

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basis to take place within 6 weeks.

Investigation of children 6 months - 3 years

Test Responds well to Atypical UTI Recurrent UTI

treatment within 48
hours

Ultrasound during No Yesª No

acute infection

Ultrasound within 6 No No Yes

weeks

DMSA 4-6 months No Yes Yes

following acute
infection

MCUG No Noᵇ Noᵇ

ª In an infant or child with a non-E.coli UTI, responding well to antibiotics and with
no other features of atypical infection, the USS can be requested on a non-urgent
basis to take place within 6 weeks.
ᵇ While MCUG should not be performed routinely, it should be considered if the
following features are present:
- dilatation on ultrasound
- poor urine flow
- non-E.coli infection
- FH of VUR

Investigation of children over 3 years

Test Responds well to Atypical UTI Recurrent UTI

treatment within 48
hours

Ultrasound during No Yesª ᵇ No

acute infection

Ultrasound within 6 No No Yesª

weeks

DMSA 4-6 months No No Yes

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following acute
infection

MCUG No No No

ª Ultrasound in toilet-trained children should be performed with a full bladder with an

estimate of bladder volume before and after micturition
ᵇ In an infant or child with a non-E.coli UTI, responding well to antibiotics and with
no other features of atypical infection, the USS can be requested on a non-urgent
basis to take place within 6 weeks.

Information about each of these investigations is included in the Appendix.

NOTE – for MCUG, a prescription is to be completed by the person requesting the test, for
treatment dose antibiotics for 3 days. They also need to advise the family that this to be taken
on the day pre-procedure, the day of the procedure and the day following it.
Antibiotic choices include trimethoprim, nitrofurantoin or cefalexin depending on sensitivity of the
infecting organism. If a patient is already on antibiotic prophylaxis, the dose should be increased
to treatment dose for the three day period as described.

3.6 Use of prophylaxis/prevention of recurrence

● Dysfunctional elimination syndromes and constipation should be treated in any children

who have had a UTI.
● Encourage to drink an adequate amount
● Encourage voiding whenever required and avoid delaying.

Antibiotic prophylaxis is not routinely required following a first UTI and should only be prescribed
following discussion with the patient’s consultant.
The recommendation at SCH is that prophylaxis should be considered if initial ultrasound scan
is abnormal and may indicate dilated vesicoureteric reflux (VUR), especially if <1 year, and if
grade III-V VUR is found on MCUG with a history of recurrent UTI.
Account should be taken of:
1) underlying causes and investigations
2) uncertain evidence of benefit for reducing the risk of recurrent UTI and the rate of
deterioration of renal scars.
3) Severity and frequency of previous symptoms
4) Risk of long term antibiotic use
5) Risk of developing complications
6) Previous urine culture and sensitivity results
7) Previous antibiotic use which may have led to resistant bacteria
8) Preference for antibiotic use
Antibiotic prophylaxis requires review at least every 6 months.

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3.7 Follow up
● Infants and children who are asymptomatic following an episode of UTI should not
routinely have their urine retested for infection

● When the results of further investigations are normal, an outpatient follow up appointment
is not routinely required, but parents or carers should be informed of all results in writing
and copied to the GP.

● Paediatric follow up:

- Infants < 6 months old
- Infants and children who have recurrent or atypical UTI
- Patients on prophylactic antibiotics
- Unilateral scarring - annual review including:
1) height and weight
2) blood pressure
3) routine testing for proteinuria
4) assessment of renal function (at baseline and then according to clinical review)
These patients should have a repeat USS at 5 years except where indicated
sooner. If normotensive and infection free at 5 years, it may be appropriate to
discharge with yearly blood pressure measurements by GP.
If recurrent UTIs, or FH or lifestyle risk factors for hypertension they should
remain under hospital follow up.

● Referral to paediatric nephrology:

- Bilateral renal abnormalities or scarring
- Impaired kidney function
- raised blood pressure
- proteinuria
- Recurrent UTI despite prophylaxis

● Referral to paediatric urology:

- Severe vesicoureteric reflux (grade 3 or above)
- Significant hydronephrosis on USS in absence of reflux on MCUG

4. References
NICE clinical guideline CG54 - Urinary tract infections in under 16s: diagnosis and
management. 2007 (2018 update) https://www.nice.org.uk/guidance/cg54

Nottingham Children’s Hospital guideline - Urinary Tract Infection. 2017.

https://www.nuh.nhs.uk/download.cfm?doc=docm93jijm4n853 accessed 11 May 2020

NICE clinical guideline N111 - Pyelonephritis (acute): antimicrobial prescribing. 2018.

https://www.nice.org.uk/guidance/ng111

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Urinary Tract Infection (UTI)

NICE clinical guideline NG109 - Urinary tract infection (lower): antimicrobial prescribing. 2018.
https://www.nice.org.uk/guidance/ng109/chapter/Recommendations

NICE guideline NG112 - Urinary tract infection (recurrent): antimicrobial prescribing. 2018.
https://www.nice.org.uk/guidance/ng112

Appendix

Technique for suprapubic aspiration (SPA) of urine

Before suprapubic aspiration is attempted, ultrasound guidance should be used to demonstrate

the presence of urine in the bladder.

1. Infant should be held in supine position by a nurse on a firm surface with their
legs extended, e.g. by placing hand across knees and also held around the
shoulders.
2. Clean lower abdomen with alcohol swab
3. Use a 10ml syringe and 21G needle
4. Insert the needle at right angles to the skin in the midline approximately 1cm
above the symphysis pubis.
5. Aspirate on the syringe once the bevel of the needle is through the skin.
6. Advance the needle downwards, maintaining suction and keep it at right angles
to the skin.
7. When urine begins to be aspirated into the syringe, stop advancing the needle.
8. Once enough urine has been obtained, the needle can be removed. No dressing
is required.

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Suprapubic aspiration may initiate micturition and a suitable container should be kept within
reach to catch the voided urine if possible. Some haematuria may follow the procedure but is
usually transient, not lasting >24 hours. Accidental penetration of the bowel may occur, but the
risk is minimised by continual suction on the needle as it is inserted; if this does occur, serious
sequelae are rarely seen.

Information about relevant imaging investigations

- Ultrasound scan aims to look at anatomy and “drainage” or the urinary system. It gives
information about the size, position and parenchymal appearance of the kidneys and about any
dilatation of the upper urinary tract and ureters. The appearance of the bladder together with the
bladder volume and emptying are also assessed. Indirect evidence that may suggest the
presence of vesicoureteric reflux such as ureteric or pelvicalyceal dilatation, uroepithelial
thickening or increased dilatation of upper tracts after micturition may also be seen.

- DMSA is a radionuclide scan that involves injection of technitium labelled DMSA. This
accumulates in the renal tubules and scanning by gamma camera 3-4 hours later gives images
of the kidneys. Information is given about relative renal function and any parenchymal
abnormality such as scarring.

- MCUG is a contrast study which gives an outline of the anatomy of the lower urinary tract and
looks for evidence of VUR. It involves insertion of a urinary catheter and instilling a contrast
medium into the bladder. Filling is monitored by fluoroscopy and micturition is induced by reflex
(with a full bladder) in infants or is volitional in continent children. MCUG is recognised to be a
difficult procedure to undertake.
It requires a prescription to be completed by the person requesting the test, for treatment
dose antibiotics for 3 days. They will also need to advise the family that this to be taken on
the day pre-procedure, the day of the procedure and the day following it.
Antibiotic choices include trimethoprim, nitrofurantoin or cefalexin depending on sensitivity. If a
patient is already on antibiotic prophylaxis, the dose should be increased to treatment dose for
the three day period as described.

Author: Lauren Tunstall, ST4 and Grace Ehidiamhen, Consultant. Review date: Feb 2023
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