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Recurrent UTI's in Children Care Pathway Overview

This pathway has been published in response to a request from primary care for further clarity around the management of children with recurrent urinary tract infections (UTIs).

Please click the relevant flowchart box to be taken directly to textual information.

                                             

Presentation

Definitions

Includes seriously ill, poor urine flow, abdominal or bladder mass, raised creatinine, septicaemia, failure to respond to treatment with suitable antibiotics within 48 hours, infection with non-E.coli organisms.

Includes 2 or more episodes of UTI with acute pyelonephritis/upper urinary tract infection, or 1 episode of UTI with acute pyelonephritis/upper urinary tract infection plus 1 or more episode of UTI with cystitis/lower urinary tract infection, or 3 or more episodes of UTI with cystitis/lower urinary tract infection.

Age Group

Symptoms and signs
Most common to Least common

Infants younger than 3 months

Fever
Vomiting
Lethargy
Irritability

Poor feeding
Failure to thrive

Abdominal pain
Jaundice
Haematuria
Offensive urine

Infants and children, 3 months or older

Preverbal

Fever

Abdominal pain
Loin tenderness
Vomiting
Poor feeding

Lethargy
Irritability
Haematuria
Offensive Urine
Failure to thrive

Verbal

Frequency
Dysuria

Dysfunctional voiding
Changes to continence
Abdominal pain
Loin tenderness

Fever
Malaise
Vomiting
Haematuria
Offensive urine
Cloudy urine

Red Flags
  • Pyelonephritis – fever, chills and loin pain in older children
Age 3 months and under:
Upon presentation, refer to paediatric consultant on 0300 422 5800 for further assessment and treatment.
Age 3 months to 3 years:
Refer to paediatric consultant on 0300 422 5800 if unwell or signs or Pyelonephritis.
Differential Diagnosis
  • Pyelonephritis
  • Non-specific vulvovaginitis
  • Chemical/irritant/STD urethritis
  • Appendicitis
  • Pelvic inflammatory disease
  • Nephrolithiasis
  • Gastroenteritis
  • Dysfunctional elimination
  • Diabetes mellitus
Initial Primary Care Assessment

 Testing for UTI

Age: 3 months to 3 years

Urgent Microscopy, culture and sensitivities (MC&S)

Age: 3 years to 16 years

Urine dipstick (plus MC&S if indicated)

Dipstick Testing for Leukocyte Esterase and Nitrate

Practice Point
Dipstick testing for leukocyte esterase and nitrate is diagnostically as useful as microscopy and culture, and can safely be used for children over the age of 3 years.

A clean catch urine sample is the recommended method for urine collection. If a clean catch is unobtainable:

Other non-invasive methods such as urine collection pads should be used. It is important to follow the manufacturer’s instructions when using urine collection pads. Cotton wool balls, gauze and sanitary towels should not be used to collect urine in infants and children.

If an infant or child with a high risk of serious illness, it is highly preferable that a urine sample is obtained; however, treatment should not be delayed if a urine sample is unobtainable.

As with all diagnostic tests there will be a small number of false negative results; therefore clinicians should use clinical criteria for their decisions in cases where urine testing does not support the findings.

If urine is to be cultured but cannot be cultured within 4 hours of collection, the sample should be refrigerated or preserved with boric acid immediately.

Results

The child should be regarded as having UTI and antibiotic treatment should be started. If a child has a high or intermediate risk of serious illness and/or a past history of previous UTI, a urine sample should be sent for culture.

Antibiotic treatment should be started if the urine test was carried out on a fresh sample of urine. A urine sample should be sent for culture. Subsequent management will depend upon the result of urine culture.

A urine sample should be sent for microscopy and culture. Antibiotic treatment for UTI should not be started unless there is good clinical evidence of UTI (for example, obvious urinary symptoms). Leukocyte esterase may be indicative of an infection outside the urinary tract which may need to be managed differently.

The child should not be regarded as having a UTI. Antibiotic treatment for UTI should not be started, and a urine sample should not be sent for culture. Other causes of illness should be explored.

Imaging

Practice Point

No need for imaging (Ultrasound scan (USS) or Dimercaptosuccinic acid radioactive tracer (DMSA)) in infants over 6 months of age with an uncomplicated/typical UTI that responds well to antibiotics within 48 hours.

Age: 6 months or under

Follow up USS within 6 weeks of a treated infection (via ICE) if responds well to treatment within 48 hours.

If recurrent/complicated/atypical may require USS during infection and follow up DMSA within 4-6 months and micturating cystourethrogram (MCUG)

Age: 6 months to 3 years

Atypical
USS during infection and follow up DMSA within 4-6 months

Recurrent
USS within 6 weeks and DMSA within 4-6 months and referral via NHS e-Referral Service (Children – Nephrology – Dr Sambo)

Age: 3 years – 6 years

Atypical
USS during infection

Recurrent
Non urgent USS (within 6 weeks) and DMSA within 4-6 months

 DMSA and MCUG are available to GPs and will be processed if appropriate pathway followed. 

Initial Primary Care Management

Antibiotic Regimens

0-3 months

N/A – child to be seen in acute setting

 

3 months – 18 years

Trimethoprim: 4mg/kg orally twice daily (max. 200mg per dose)

Or

Nitrofurantoin : 3 months – 12 years: 0.75mg/kg orally four times a day

Nitrofurantoin: 12 years – 18 years: 50mg orally four times a day or modified release 100 mg orally twice a day increased to 100mg four times a day in severe recurrent infections

NOTE: Nitrofurantoin contraindicated in renal failure see CBNF or BNF

Duration of course for lower UTI

3 days (male and female children)

0-3 months

N/A – child to be seen in acute setting

3 months – 18 years

Co-amoxiclav: 3 months – 1 year: 0.25 – 0.5mL/kg of 125/31 suspension orally three times a day

Co-amoxiclav: 1 year – 6 years: 0.25 – 0.5mL/kg of 125/31 suspension orally three times a day  OR 5 – 10 mL of 125/31 suspension orally three times a day

Co-amoxiclav: 6 years – 12 years: 0.15 – 0.3mL/kg of 250/62 suspension orally three times daily OR 5-10mL of 250/62 suspension orally three times a day (max. 10ml per dose)

Co-amoxiclav: 12 years – 18 years: 375 – 625mg orally three times a day

Duration of course for upper UTI

7 – 10 days

Practice Point

If patient has a penicillin allergy:

Ciprofloxacin: 3 months – 18 years: 20mg/kg orally twice a day (max 750mg/dose)

When to Refer

Age 3 months and under:

Upon presentation, refer to paediatric consultant on 0300 422 5800 for further assessment and treatment.

Age 3 months to 3 years:

Refer to paediatric consultant on 0300 422 5800 if unwell or signs or Pyelonephritis.

Any age:

If recurrent UTI’s or abnormal imaging refer via NHS e-Referral Service (Children – Nephrology – Dr Sambo).

Secondary Care Management - GHFT

Local follow up by paediatrician with renal interest (Dr Sambo) is organized, with tertiary input for complex cases with established chronic kidney disease (CKD). Such patients will require lifelong monitoring of blood pressure and urine dipstick for proteinuria detection within primary care setup.

Ongoing Primary Care Management

For patients with established CKD, lifelong monitoring in Primary Care of blood pressure and urine dipstick for proteinuria detection will be required.

Ensure children and young people, their parents or carers are aware of UTI recurrence and understand when to seek treatment for suspected reinfection. Provide patient/carer leaflets and verbal information.

The Gloucestershire Specialist Continence Service is based at Gloucestershire Royal Hospital and holds clinics across the county and within special schools.  The service works with children and young people, and their families or carers, to promote and achieve continence through proactive toilet training.  The service aims to improve the clinical outcomes and quality of life for children and young people and their families through evidence-based treatment that promotes continence, preventing unnecessary long-term reliance on nappies and pads and the possible need for surgery

The Specialist Continence Service offers a wide range of interventions ranging from tips and techniques to motivate your child and develop their skills, to drug treatments and bedwetting alarms as part of a more complex and comprehensive treatment plan.  Whatever the approach, it is tailored to the needs and circumstances of your child or young person and your family following a comprehensive assessment of need.

The Specialist Continence Service provides on-going support and products tailored to the needs of children and young people.  Appointments are scheduled for a review of progress at least every 6 months.

Referrals - If the child has worked with the Health Visitor or School Nurse for 3 months with no improvement, it may be that further advice/support is required and the Health Visitor or School Nurse may refer the child onto the Children and Young People’s Specialist Continence Service.

GPs should not refer directly to the Specialist Continence Service in the first instance unless the child has special needs or complex bladder or bowel problems.

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