Urinary tract infection – Emergency management in children

Purpose

This document provides clinical guidance for all staff involved in the care and management of a child presenting to an Emergency Department (ED) with symptoms suggestive of a urinary tract infection (UTI) in Queensland.

This guideline has been developed by senior ED clinicians and Paediatricians across Queensland, with input from Infectious diseases, Pharmacy and Nephrology, Queensland Children’s Hospital, Brisbane. It has been endorsed for use state-wide by the Queensland Emergency Care of Children Working Group in partnership with the Queensland Emergency Department Strategic Advisory Panel and the Healthcare Improvement Unit, Clinical Excellence Queensland.

Introduction

UTIs are common in childhood. An estimated 2% of boys and 8% of girls will experience a UTI by seven years of age. UTIs are the most common SBI in children aged less than 5 years.^1-3

Assessment

Non-specific clinical presentation and difficulties in obtaining urinary specimens in infants and young children can make the diagnosis of UTI challenging.^1-6

Consider a sepsis diagnosis in child presenting with toxic features including tachypnoea, increased work of breathing, grunt, weak cry, marked/persistent tachycardia, moderate to severe dehydration. Refer to the sepsis pathway.

Refer to the Febrile illness guideline for the assessment of children with a fever ≥38⁰ C without localising signs. In general, the younger the infant or child, the lower the threshold for urine screening.^3-6

History

The clinical features on history are variable and age-dependant.

History should also include specific information on:

• fever and use of anti-pyretics
• presence of pain including loin or suprapubic tenderness and use of analgesia
• difficulties passing urine (where age-appropriate)
• presence of underlying conditions associated with an increased risk of UTI (refer to Introduction)

Examination

Physical examination should include a thorough abdominal examination (to identify masses or suggestion of pyelonephritis), examination of external genitalia (to identify genitourinary abnormalities which predispose to UTI), lower limb neurological examination (impaired bladder emptying due to neurological aetiology) and hydration status. Blood pressure should be measured.

No physical sign is pathognomonic for a UTI.^7,8 Other than fever, signs may include hypertension, a palpable bladder, dribbling or straining, and loin or suprapubic tenderness. Distinguishing clinically between lower (cystitis) and upper (pyelonephritis) UTI can be challenging. Pyelonephritis is more likely in younger infants, and more likely to have systemic features such as fever (with rigors), vomiting, malaise and loin tenderness.

Investigations

Urine testing

All children who present with urinary symptoms should undergo urine testing.

In addition, all neonates who present with a fever ≥38⁰ C should have urine sent for microscopy to screen for UTI.^3,6,9 A step-by-step approach can be taken for children aged between 29 days to 3 months, with a low threshold to consider UTI as a diagnosis.^3,6 Urine testing can be safely deferred in children with an unexplained fever who are ≥3 months of age and otherwise well.⁴ For these children urine testing is only recommended if fever persists for more than 48 hours.⁵ Refer to the Febrile illness guideline for the additional investigations recommended in children with an unexplained fever.

Urine testing is not recommended on first presentation for children aged ≥3 months who have a clear alternative site of infection, and if verbal, no urinary symptoms.⁵ Consider testing for those who remain unwell on subsequent review.

Urine collection methods

The most appropriate urine collection method varies depending on age and clinical presentation.^2,4,6

Well appearing children over 12 months of age with an unexplained fever can be discharged with a urine jar to collect a specimen for urine microscopy via their GP if assessment has otherwise been completed.

In catheterised children, collect a specimen and contact the treating team. Catheters should only be exchanged on specialist advice.

UTI diagnosis

Dipstick urinalysis

Urine microscopy

Urine microscopy can be used as an additional screening tool to dipstick testing. The presence of bacteria and leucocytes on microscopy in a sample with less than 10 epithelial cells per high powered field are suggestive of UTI.⁸

Other investigations

Investigations including USS and bloods are not routinely recommended.

Consider imaging (initially ultrasound) for the following children:

• upper renal tract features
• recurrent UTI (to identify/exclude a structural abnormality).

Consider sexually transmitted infection (STI) screening including gonorrhoea and chlamydia PCR testing on first pass urine where appropriate.

Management

Refer to flowchart [PDF 300.46 KB] for a summary of the emergency management of children presenting with a urinary tract infection.

Child with toxic features

Seek urgent paediatric critical care advice (onsite or via Retrieval Services Queensland (RSQ)) for a child with life-threatening sepsis.

Seek senior emergency/paediatric advice if sepsis is suspected.

Children with apparent sepsis or in shock should be treated with parenteral antibiotics and intravenous fluids – refer to CHQ Antibiocard and the Queensland Paediatric Sepsis Pathway. Refer to the Sepsis guideline for recommended investigations.

Consider a lumbar puncture in neonates (age less than 29 days) with a UTI given the relatively higher incidence of co-existing meningitis.^15-16

Child with no toxic features

Seek senior emergency/paediatric advice as per local practice for the following children:

• age less than three months
• upper renal tract features
• renal tract anomalies
• long-term catheter
• on prophylactic antibiotics

Uncomplicated presentation of UTI in child aged three months or more

Empiric antibiotic therapy is recommended following a presumptive UTI diagnosis on dipstick testing or initial urine microscopy while the sample is being cultured and tested for sensitivities.

Treatment is age-dependent and should be tailored to clinical severity. Broad spectrum oral antibiotics will treat most uncomplicated UTIs. In the non-vomiting child, oral antibiotics are as effective as parenteral antibiotics due to high urinary concentrations.^17-18

Antibiotics IV are recommended for children who are unable to tolerate oral antibiotics. Some hospitals may have a HITH (hospital in the home) program to facilitate this.

Clinicians working in Townsville [PDF] (access via QH intranet), Cairns (access via QH intranet) and Gold Coast University Hospital and Health Services should follow their local paediatric empirical antimicrobial therapy guidelines. Clinicians elsewhere in Queensland should follow the Children’s Health Queensland paediatric antimicrobial prescribing guidelines until the results of microbiological investigations are available.

Special considerations

Children less than three months of age

Administer empiric antibiotic therapy following a presumptive UTI diagnosis on initial urine microscopy while the sample is being cultured and tested for sensitivities.

Antibiotics IV are recommended for all infants less than three months of age due to the higher risk of bacteraemia, sepsis and mortality.

Links to empirical antibiotic guidelines

• Cairns (access via QH intranet)
• Children’s Health Queensland
• Gold Coast
• Townsville [PDF] (access via QH intranet)
• Queensland Statewide Paediatric Sepsis Clinical Pathway

Co-existing meningitis can occur especially in neonates.^15-16 Seek senior advice regarding lumbar puncture for an infant with a presumptive UTI diagnosis.

Children with suspected pyelonephritis/peri-nephric abscess

Patients with a presumptive UTI diagnosis and loin/flank pain, renal angle tenderness or abdominal pain, should be investigated for pyelonephritis or a perinephric abscess. Recommended investigations include a FBC, renal function, blood culture and an ultrasound of the renal tract to identify a perinephric collection.

Children on prophylactic antibiotics

Prophylactic antibiotics are typically changed to an empiric antibiotic until definitive cultures and sensitivities are obtained. Discuss with the child’s General Paediatrician.

Children with catheters

Pyuria should not be used as the sole criteria for the diagnosis of UTI in catheterised children. Bacterial colonisation of long-term catheters is common, and these children are often asymptomatic despite pyuria and bacteriuria.⁴

Empiric and/or prophylactic antibiotics should be decided on a case by case basis, ideally after discussion with the child’s General Paediatrician and where relevant, Infectious Disease physician and Surgical team. Improper use of antibiotics in this cohort may encourage the development of antibiotic resistance.

Children with renal tract anomalies

Empiric antibiotics in children with renal tract anomalies (including congenital genitourinary tract malformations, dysfunctional or surgically altered urinary tract) should be decided on a case by case basis, ideally after discussion with their General Paediatrician and where relevant Infectious Disease physician and Surgical team. Improper use of antibiotics in this cohort may encourage the development of antibiotic resistance.

Sexually active children

Sexually transmitted infections (STIs) can have a similar clinical presentation to UTIs.¹⁹ Untreated STIs may lead to poor fertility and pelvic inflammatory disease. Consider gonorrhoea and chlamydia PCR testing on first pass urine in older symptomatic children. Children diagnosed with a gonorrhoea or chlamydia infection may require testing for other sexually transmitted disease (i.e. HIV, Hepatitis B or C).

Escalation and advice outside of ED

Clinicians can contact the services below if escalation of care outside of senior clinicians within the ED is needed, as per local practices. Most children will be managed as an outpatient.

Critically unwell or rapidly deteriorating child

Non-critical child

Inter-hospital transfers

Disposition

When to consider discharge from ED

Discharge with GP follow-up of culture and sensitivity results may be considered for relatively well children aged three months or older.

Seek senior emergency/paediatric advice prior to considering discharge for all children with fever aged between 29 days and 3 months regardless of urine microscopy results.

On discharge educate carers on measures to minimise the risk of future UTIs including:

• management of constipation
• adequate fluid intake to allow clear light-coloured urination
• wiping front to back in toileting
• wearing breathable fabric underwear

Follow-up

• with GP in 1-2 days for clinical review and urine culture and sensitivity results.
• consider renal tract ultrasound (via GP) in the following children:
  • age less than 1 year with presumptive UTI
  • recurrent or atypical UTIs

When to consider admission

Admission is recommended for the following children:

• infants less than 3 months with a presumptive UTI
• neonates with a fever regardless of urine microscopy results (refer to the Febrile illness guideline)
• children requiring antibiotics IV

Consider admission and further investigation (including renal ultrasound) for the following children:

• suspected concurrent bacteraemia pending laboratory confirmation
• urine culture with atypical organisms (e.g. Staphylococcus aureus or Pseudomonas aeruginosa)

Related documents

Guidelines

• NICE Guideline Urinary tract infection in under 16s: diagnosis and management
• Sepsis: Recognition and emergency management in children
• Febrile Illness – Emergency management in children
• Meningitis – Emergency management in children

Factsheet

• UTI factsheet
• How to collect a clean urine specimen factsheet