Diagnosis and management of urinary tract infection in children: summary of NICE guidanceBMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39286.700891.AD (Published 23 August 2007) Cite this as: BMJ 2007;335:395
- Rintaro Mori, research fellow1,
- Monica Lakhanpaul, clinical co-director for guidelines, and senior lecturer in child health2,
- Kate Verrier-Jones, reader in child health, Cardiff University, and honorary consultant paediatric nephrologist, University Hospital of Wales3
- 1National Collaborating Centre for Women's and Children's Health, Royal College of Obstetricians and Gynaecologists, London NW1 4RG
- 2National Collaborating Centre for Women's and Children's Health, Royal College of Obstetricians and Gynaecologists, and University of Leicester, Leicester
- 3Cardiff and Vale NHS Trust, Cardiff CF14 4XN
- Correspondence to: M Lakhanpaul
Why read this summary?
Although urinary tract infection affects at least 3.6% of boys and 11% of girls, establishing the diagnosis is difficult in early childhood owing to the lack of specific urinary symptoms, difficulty in urine collection, and contamination of samples. Most children have a single episode and recover promptly. Current imaging, prophylaxis, and prolonged follow-up strategies place a heavy burden on patients, families, and NHS resources and carry risks without evidence of benefit. This article summarises the most recent guidance from the National Institute for Health and Clinical Excellence (NICE) on how to provide consistent clinically and cost effective practice for the diagnosis, treatment, and further management of urinary tract infection in childhood.1
NICE recommendations are based on systematic reviews of best available evidence. When minimal evidence is available, a range of consensus techniques is used to develop recommendations. In this summary, recommendations derived primarily from consensus techniques are indicated with an asterisk (*).
Assessment and diagnosis
• Consider a diagnosis of urinary tract infection in all infants and children with:
(a) unexplained fever of 38°C or higher after 24 hours at the latest
(b) symptoms and signs suggestive of urinary tract infection, including:
- non-specific symptoms, such as lethargy, irritability, malaise, failure to thrive, vomiting, poor feeding, abdominal pain, jaundice (in infants)
- specific symptoms, such as frequency, dysuria, loin tenderness, dysfunctional voiding, changes to continence, haematuria, and offensive or cloudy urine.
• Collect a urine sample:
(a) do this preferably by clean catch, but if this is not possible, use a urine collection pad but not cotton wool balls, gauze, or sanitary towels.
(b) if non-invasive techniques are not possible, use a catheter sample or suprapubic aspirate with ultrasound guidance.
• Test the urine sample: for infants younger than 3 months, refer to a paediatric specialist, who should send urine for urgent microscopy and culture; for children 3 months or older but younger than 3 years, see box 1; for children 3 years or older, see box 2.
• Send urine for culture when any of the following apply*:
- age younger than 3 years
- clinical diagnosis of acute pyelonephritis or upper urinary tract infection
- high to intermediate risk of serious illness2
- history of recurrent urinary tract infection
- single positive dipstick result for leucocyte esterase or nitrite
- infection does not respond to treatment within 24-48 hours, if no sample has already been sent
- clinical symptoms and dipstick tests do not correlate.
Localising site of urinary tract infection*
• Consider any child with bacteriuria and fever of 38°C or higher as having acute pyelonephritis or upper urinary tract infection.
• Consider any child with fever lower than 38°C, loin pain or tenderness, and bacteriuria as having acute pyelonephritis or upper urinary tract infection.
• Consider all other children with bacteriuria but no systemic symptoms or signs as having cystitis or lower urinary tract infection.
History, examination, and documentation
• Ensure history and examination, and document the presence or absence of features of atypical illness and markers of underlying pathology.*
• Children with a high risk of serious illness2 and/or younger than 3 months: refer immediately to secondary care
• Children aged 3 months and older with acute pyelonephritis or upper urinary tract infection:
- consider referral to secondary care
- treat with 10 days of oral antibiotics, or if child is unable to tolerate oral antibiotics, start treatment with intravenous antibiotics until oral intake is possible
- repeat culture if no response within 24-48 hours
• Children aged 3 month and over with cystitis or lower urinary tract infection:
- treat with three days of oral antibiotics according to local guidance
- advise carers to return for review if the child remains unwell after 24-48 hours.
• Do not prescribe antibiotic prophylaxis routinely.
• Children of all ages with atypical urinary tract infection (box 3): perform ultrasonography of the urinary tract during the acute infection to identify structural abnormalities of the urinary tract.
• Infants younger than 6 months with first time urinary tract infection that is responsive to treatment: do ultrasonography within six weeks of the infection.
• Children younger than 3 years with atypical and/or recurrent urinary tract infection (box 3): do a DMSA (dimercaptosuccinic acid) scan 4-6 months after the acute infection to detect renal parenchymal defects.
• Do not do routine imaging to identify vesicoureteral reflux.
Referral and follow-up*
• Referral to paediatric care specialist for children with abnormal imaging findings and after recurrent urinary tract infection.
Information and advice for children, young people, and parents or carers*
• Appropriate information and advice must be provided at each stage, including:
- the possibility of a urinary tract infection recurring
- the need to be vigilant and seek prompt treatment from a healthcare professional for any suspected reinfection.
Box 1 Initial management of children 3 months or older but younger than 3 years: use urgent microscopy and culture to diagnose urinary tract infection
Specific urinary symptoms
• Send urine sample for urgent microscopy and culture; if urgent microscopy is not available, send a urine sample for microscopy and culture
• Start antibiotic treatment
High risk of serious illness
• Refer child urgently to paediatric specialist care
• Send urine sample for urgent microscopy and culture
• Manage in line with NICE clinical guideline on feverish illness in children2
Intermediate risk of serious illness
• Consider urgent referral to a paediatric specialist (see NICE guideline2)
• When specialist paediatric referral is not required:
- arrange urgent microscopy and culture
- start antibiotic treatment if microscopy is positive
- consider dipstick testing if urgent microscopy is not available
- start antibiotic treatment if nitrites are present (these suggest the possibility of infection)
• In all cases, a urine sample should be sent for microscopy and culture
Low risk of serious illness:
• Send urine sample for microscopy and culture
• Start antibiotic treatment if microscopy or culture is positive
Box 2 Initial management of children 3 years or older: use dipstick test to diagnose urinary tract infection
If leucocyte esterase and nitrite are positive
• Start antibiotic treatment for urinary tract infection
• If child has high or intermediate risk of serious illness or a history of infection, send urine sample for culture
If leucocyte esterase is negative and nitrite is positive
• Start antibiotic treatment if fresh sample was tested
• Send urine sample for culture
If leucocyte esterase is positive and nitrite is negative
• Send urine sample for microscopy and culture
• Only start antibiotic treatment for urinary tract infection if there is good clinical evidence of such infection
• Result may indicate infection elsewhere
• Treat depending on results of culture
If leucocyte esterase and nitrite are negative
• Do not start treatment for urinary tract infection
• Explore other causes of illness
• Do not send urine sample for culture unless recommended (see recommendations on urine culture)
Box 3 Main characteristics of patients with atypical or recurrent urinary tract infection
Atypical (any of the following)
• Septicaemia or patient who looks seriously ill (see NICE guideline2)
• Poor urine flow
• Abdominal or bladder mass
• Raised creatinine concentration
• Failure to respond to treatment with suitable antibiotics within 48 hours
• Infection with non-Escherichia coli organisms
Recurrent (any of the following)
• Two or more episodes of urinary tract infection with acute pyelonephritis or upper urinary tract infection
• One episode of urinary tract infection with acute pyelonephritis or upper urinary tract infection plus one or more episode of urinary tract infection with cystitis or lower urinary tract infection
• Three or more episodes of urinary tract infection with cystitis or lower urinary tract infection
Despite strongly held views by some clinicians about the role of intensive imaging strategies and prophylactic antibiotic treatment in preventing renal failure after urinary tract infection, current evidence shows no such benefit. The most useful strategy for reducing morbidity from urinary tract infection and preventing subsequent renal parenchymal defects is the prompt diagnosis and treatment of the infection. This is particularly important in infants and young children, in whom the diagnosis can easily be missed.
NICE has developed tools to help organisations implement the guidance (see www.nice.org.uk/page.aspx?o=tools).
• Whiting P, Westwood M, Bojke L, Palmer S, Richardson G, Cooper J, et al. Clinical effectiveness and cost-effectiveness of tests for the diagnosis and investigation of urinary tract infection in children: a systematic review and economic model. Health Technology Assessment 2006;10 (No 36).
• Jepson RG, Mihaljevic L, Craig JC. Cranberries for treating urinary tract infections. Cochrane Database Syst Rev 1998;(4):CD001322.
• Michael M, Hodson EM, Craig JC, Martin S, Moyer VA. Short versus standard duration oral antibiotic therapy for acute urinary tract infection in children. Cochrane Database Syst Rev 2003;(1):CD003966.
• Williams GJ, Wei L, Lee A, Craig JC. Long-term antibiotics for preventing recurrent urinary tract infection in children. Cochrane Database Syst Rev 2006;(3):CD001534.
• Bloomfield P, Hodson EM, Craig JC. Antibiotics for acute pyelonephritis in children. Cochrane Database Syst Rev 2005;(1):CD003772.
• Wheeler DM, Vimalachandra D, Hodson EM, Smith GH, Craig JC. Interventions for primary vesicoureteric reflux. Cochrane Database Syst Rev 2007;(3):CD001532.
Further information on the guidance
The most recent previous guidance on imaging after urinary tract infection in childhood was published by the Royal College of Physicians in 1991.3 In a national audit of the guideline reported in 20014 5 (which included 746 children under 2 years old with a fever in 31 hospitals) testing for possible urinary tract infection was highly variable. Altogether, 38/74 infants with a positive result on urine culture were not given a diagnosis of urinary tract infection and did not receive any treatment, prophylaxis, imaging, or follow-up. There was also no communication with the general practitioner or the patient's carers about the positive culture result. Thus half of the infants and children seen in secondary care with evidence for urinary tract infection did not receive the correct diagnosis or recommended management.
Imaging and follow-up of correctly diagnosed cases were assessed in a second study and showed that 93% of children had at least an ultrasound scan, and only 5% had no imaging test, indicating a high degree of compliance with the imaging strategy.
The new NICE guidance1 proposes that:
• Dipstick urine testing is the first line investigation for children aged 3 years or older
• Urgent microscopy and culture is the first line investigation for children younger than 3 years (dipsticks are recommended for use only as a substitute when transport of a sample to the laboratory is impossible and the child has a low to intermediate risk of serious illness)
• Antibiotic treatment duration is influenced by clinical evidence of acute pyelonephritis or upper urinary tract infection
• Routine prophylactic antibiotics are not recommended
• Imaging tests are only for those with an increased risk of developing serious renal consequences, including infants under 6 months, and all children with atypical or recurrent urinary tract infection.
The guideline was developed by the National Collaborating Centre for Women and Children's Health. The collaborating centre convened a Guideline Development Group consisting of two paediatric nephrologists, one general paediatrician, one general practitioner, one paediatric urologist, one paediatric radiologist, one paediatric microbiologist, two paediatric nurses, and one patient/carer representative. Technical support was provided by the collaborating centre.
The guideline was developed according to the standard NICE methods (www.nice.org.uk/page.aspx?o=howwework) and checked against a wider stakeholder community of clinicians, methodologists, researchers, patient/carers, and policy makers.
NICE has produced four different versions of the guideline: a full version; a quick reference guide; a version known as the “NICE guideline” that summarises the recommendations; and a version for patients and the public. All these versions are available from the NICE website (www.nice.org.uk/CG054).
Future updates of the guideline will be produced as part of the NICE guideline development programme.6
• The diagnostic accuracy of dipstick tests for nitrites and leucocyte esterase (separately and in combination) needs further evaluation in studies stratified by age and method of urine collection.
• Well designed randomised, double blind, placebo controlled trials are required to determine the effectiveness of prophylactic antibiotics for preventing subsequent symptomatic urinary tract infections and renal parenchymal defects in children.
• Well designed randomised, placebo controlled trials are required to determine the effectiveness of various surgical procedures for vesicoureteral reflux in preventing recurrent urinary tract infection or renal parenchymal defects.
• A well designed cohort study investigating long term outcomes (including renal scarring and renal function) of children who have had urinary tract infection should be conducted in the United Kingdom.
Guideline Development Group
The members of the Guideline Development Group were Kate Verrier Jones, Jay Banerjee, Su-Anna Boddy, David Grier, Lyda Jadresic, James Larcombe, Julie Marriott, Jeni Senior, Kjell Tullus, Sue Vernon, and Craig Williams, with Monica Lakhanpaul, Rintaro Mori, Anita Fitzgerald, Jeff Round, Michael Corkett, Samantha Vahidi, and Rosie Crossley from the National Collaborating Centre for Women's and Children's Health.
This is one of a series of BMJ summaries of new guidelines, which are based on the best available evidence; they will highlight important recommendations for clinical practice, especially where uncertainty or controversy exists
Contributors: RM was the project manager and systematic reviewer; he drafted the paper, and all authors contributed to its revision and the final draft. ML is the clinical co-director for the guidelines, was the project director, and convened the Guideline Development Group. KV-J chaired the Guideline Development Group.
Competing interest: None declared.
Funding: The National Collaborating Centre for Women's and Children's Health was commissioned and funded by the National Institute for Health and Clinical Excellence to write this summary.
Provenance and peer review: Commissioned; not externally peer reviewed.