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Urinary tract infection in childhood
MRC Research Fellow and General Practitioner University of Southampton, UK
E-mail: caes{at}soton.ac.uk
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Abstract |
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 TOP Abstract The GP curriculum and...Consequences of childhood UTIsClinical presentationManagement of children with...Follow-up care of children...References |
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Eight per cent of girls and 2% of boys have a urinary tract infection (UTI) in childhood – the majority in the first year of life. Among neonates, boys have more infections than girls. In all other age groups girls are ten times more likely to have UTIs than boys. Risk factors are listed in Box 1. Most childhood UTIs are caused by normal bowel flora such as E. coli (80%), Klebsiella, Pseudomonas and other Gram-negative organisms.
Childhood urinary tract infection is common and can have serious consequences. UTI in childhood is part of the knowledge base required for GPs and the role of the GP in management of childhood UTI is covered in curriculum statement 8: Care of children and young people. GPs in training must be able to manage primary contact with children and their families, prescribe and advise appropriately about the use of medicines in children, demonstrate an understanding of the importance of multi-agency working and coordinate care with other primary care professionals, paediatricians and other appropriate specialists, leading to effective and appropriate care provision.
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Consequences of childhood UTIs |
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TOPAbstractThe GP curriculum and...Consequences of childhood UTIsClinical presentationManagement of children with...Follow-up care of children...References |
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Childhood UTI can have long-term consequences and management should be aimed both at treating the acute infection and preventing long-term effects. Around 1 in 10 children with UTI develop renal scarring within two years of their first infection. There is a higher incidence of renal scarring in children with renal tract abnormalities and vesicoureteric reflux. Infections causing renal scarring are associated with adult pyelonephritis, hypertension, impaired renal function and renal failure. Prognosis is worst for children with recurrent infection, severe reflux and renal scarring at the time of first presentation.
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Clinical presentation |
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TOPAbstractThe GP curriculum and...Consequences of childhood UTIsClinical presentationManagement of children with...Follow-up care of children...References |
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Presentation depends on the age of the child and site of the infection.
Infants and toddlers Fever is the most common presentation in this age group. Neonates may present with prolonged jaundice but generally small babies (less than 3 months old) tend to present with non-specific symptoms and signs including vomiting, irritability, fever, lethargy, and poor feeding. Older babies and toddlers also present with non-specific symptoms and signs, but may also have localizing symptoms/signs such as abdominal pain or loin tenderness. A more chronic presentation is with failure to thrive. Less frequently, small children and babies present with urinary signs such as haematuria or offensive urine.
| Box 1. Risk factors for urinary tract infection in children
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Older children
Older children tend to present with ‘classic’ symptoms of UTI – dysuria, urinary frequency, and/or abdominal pain. This may be accompanied by cloudy or offensive urine or haematuria. Systemic symptoms are less common than in younger children and include fever, malaise and vomiting. In addition, suspect UTI in any child who starts wetting him or herself during the day or wetting the bed at night once dry.
Site of infection
Children with bacteriuria but no systemic features are likely to have cystitis. Children with bacteriuria together with high temperature (more than 38oC) and/or loin pain or tenderness are likely to have acute pyelonephritis.
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Management of children with suspected UTI |
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TOPAbstractThe GP curriculum and...Consequences of childhood UTIsClinical presentationManagement of children with...Follow-up care of children...References |
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Presentation with fever Childhood infection is the most common cause of fever in children. Fever without any localizing symptoms or signs, is a common presentation of UTI in small children. Suspect urinary tract infection in any child with fever of greater than 38oC with no obvious cause.
NICE recommends a traffic light system of assessment of severity of illness for fever in children under five years (Table 1):
- Children with any ‘red’ features should be admitted as an acute paediatric emergency or have an emergency paediatric review arranged
- Children with any ‘amber’ features should be referred for same day paediatric review, reviewed later in the community, or carers should be warned about symptoms and signs that should prompt them to seek further review depending on clinical and social circumstances
- Children with only ‘green’ features can be managed at home with advice for carers on management and when to seek further help
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However, the traffic light system has been criticized as it does not allow enough room for clinical judgment or individual circumstances. In general, the younger the child, the lower the threshold should be for admission.
Urine testing
If the child is being managed at home, test a urine sample in all children with:
- Specific symptoms or signs of a urine infection
- Unexplained fever (check urine as soon as possible) or
- Fever presumed to be due to another cause (e.g. tonsillitis) but who remain unwell despite treatment or natural resolution of that problem
Urine collection can be problematic in a young child. A clean catch sample is best but a bag may be necessary. When collecting a bag specimen the child should be upright and the bag removed as soon as it has been filled to minimize contamination. Special pads are also available and are preferred by parents. It is important to indicate method of collection used when the sample is sent to the laboratory for proper interpretation of results.
A sample should be sent to the laboratory for microscopy, culture and sensitivities M,C & S for all children under three years of age with suspected UTI. A sample should also be sent to the laboratory for older children with positive urine dipstick results (Table 2). Refrigerate or preserve with boric acid any sample that cannot be delivered to the laboratory within 4 h. All symptomatic children with bacteriuria on urine microscopy should be started on antibiotics. In addition, children with pyuria but no bacteriuria should start antibiotics if they have clinical features of a urine infection.
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Initial management of children in the community
If a child has specific symptoms or signs of UTI and is under three years of age, send a sample to the laboratory for M,C & S and start antibiotics immediately, altering antibiotics as necessary later depending on sensitivities. If the child is older than three years, dipstick the urine and act on the results as in Table 2.
If a child presents with non-specific symptoms and signs such as malaise, vague abdominal pain or fever, and is well, send a urine sample to the laboratory for M,C & S and await the results. Treat with antibiotics if urinary infection is confirmed.
If the child is unwell with non-specific symptoms, but a decision has been made not to admit at present, send a urine sample to the laboratory for urgent microscopy and treat with antibiotics for UTI if bacteriuria is confirmed. If urgent microscopy services are not available, dipstick the urine and start antibiotics if the test is positive for nitrites. Always send a sample to the laboratory for M,C & S if the child is under three years of age, there is a high risk of UTI (e.g. past history, known renal tract abnormality) or the dipstick test is positive for nitrites or leucocytes.
Use a broad spectrum antibiotic with a low resistance pattern (e.g. trimethoprim suspension 50 mg/5 ml) to treat children with urinary tract infection in the community. Alter the antibiotic according to sensitivities if the organism responsible is resistant. If the child has an upper UTI/acute pyelonephritis, treat for 7–10 days. If the child has a lower UTI/cystitis, treat for 3 days. Review after 24–48 h if not improving. At that time, if no sample was sent to the laboratory before antibiotics were started, send a sample for M,C & S. Stress to the child and parents the need for treatment and importance of completing treatment.
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Follow-up care of children with proven UTI |
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TOPAbstractThe GP curriculum and...Consequences of childhood UTIsClinical presentationManagement of children with...Follow-up care of children...References |
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There is no need to restest a child's urine to check clearance of infection if the child is asymptomatic following treatment. In all cases stress the possibility of UTI recurring and the importance of remaining vigilant and seeking medical advice promptly if symptoms should return.
Treat any constipation or dysfunctional voiding patterns that may have predisposed the child to UTI. Encourage the child to drink plenty and/or the parents to offer the child lots of drinks. Stress to children that they should not hold on to their urine if they need to go to the toilet. There is no need to give prophylactic antibiotics after one urine infection, but consider prescribing prophylaxis if the child has suffered recurrent urinary infections. Usually prophylaxis is with trimethoprim suspension 1–2 mg/kg nocte.
Whether to refer for further investigation depends on how well a child responds to treatment for the initial UTI, whether the child has a typical or atypical infection (Box 2) and whether or not the child has had recurrent urine infections (Box 3). Reasons for referral and tests that should be arranged are summarized in Table 3. Arrangements for referral vary between localities. In some areas, GPs have direct access to investigations, in others referral must go via a paediatrician. If imaging is normal, explain the results to the child and parents, and reassure them that no further follow up is required. If any imaging test is abnormal, refer to paediatrics for further follow up.
| Box 2. NICE features of atypical UTI
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| Box 3. NICE definition of recurrent UTI
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2 episodes of upper UTI/pyelonephritis.
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References |
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TOPAbstractThe GP curriculum and...Consequences of childhood UTIsClinical presentationManagement of children with...Follow-up care of children...References |
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NICE UTI in children (2007) Available from http://www.nice.org.uk/guidance/index.jsp?action=byID&o=11819 [date last accessed 29.11.07].
NICE Feverish illness in children: assessment and initial management in children under 5 years Available from http://www.nice.org.uk/guidance/index.jsp?action=byID&o=11010 [date last accessed 29.11.07].
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