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Urinary tract infection in children

Implementing NICE guidance

2007

NICE clinical guideline 54

Changing clinical practice

NICE guidelines are based on the best available evidence

The Department of Health asks NHS organisations to work towards implementing guidelines

Compliance with developmental standards will be monitored by the Healthcare Commission

What this presentation covers

Background

Key recommendations

Implementation advice

Costs and savings

Resources from NICE

Background:why this guideline matters

•Urinary tract infection (UTI) is common in infants and children

•UTI is difficult to recognise

•Collecting urine and interpreting laboratory results is not easy

•Diagnosis is not always confirmed

•UTI in infants and children may have long-term sequelae

What the guideline covers

Diagnosis

•assessing signs and symptoms

•urine collection and testing

Management

•antibiotic treatment

Imaging

Follow-up

Information and advice

Key recommendations

Symptoms and signs

Urine collection

Urine testing

History and examination

Acute management

Antibiotic prophylaxis

Imaging tests

Test urine when an infant or child presents with:

• unexplained fever of 38°C or higher

or• symptoms and signs suggestive of UTI

Consider testing urine when an infant or child presents with:

• an alternative site of infection, but remains unwell

Do not test urine when an infant or child presents with:

• an obvious alternative source of fever

Assess the symptoms and signs

Presenting symptoms and signs in infants and children

with UTI•Younger than 3 months: fever, vomiting, lethargy, irritability, poor feeding, failure to thrive, abdominal pain, jaundice, haematuria, offensive urine

•3 months or older and preverbal: fever, abdominal pain, loin tenderness, vomiting, poor feeding, lethargy, irritability, haematuria, offensive urine, failure to thrive

•3 months or older and verbal: frequency, dysuria, dysfunctional voiding, changes to continence, abdominal pain, loin tenderness, fever, malaise, vomiting, haematuria, offensive or cloudy urine

Urine collection and testing A clean catch urine sample is the recommended method for urine collection

If a clean catch sample is unobtainable, use other non-invasive methods, such as urine collection pads

Do not use cotton wool balls, gauze or sanitary towels to collect urine

Catheter samples or suprapubic aspiration (SPA) should be used when urine collection is not possible by non-invasive methods

Where there is a high risk of serious illness, do not delay treatment if a urine sample is unobtainable

Urine collection and testing : suprapubic aspiration (SPA)

•Use suprapubic aspiration only when urine collection is not possible by non-invasive methods

•Ultrasound guidance should be used to demonstrate urine in the bladder before SPA is attempted

Urine collection and testing: infants younger than 3 months

Refer immediately to paediatric specialist care, where a urine sample should be sent for urgent microscopy and culture as part of the septic screen carried out prior to treatment

These infants should be managed in accordance with the recommendations for this age group in ‘Feverish illness in children’ (NICE clinical guideline 47).

Urine collection and testing: infants and children aged

3 months to 3 yearsIf the infant or child presents with specific urinary symptoms:

Urgent microscopy and culture is the preferred method for diagnosing UTI. After a urine sample is obtained, antibiotic treatment should be started. If urgent microscopy is not available, send a urine sample for microscopy and culture.

If the infant or child presents with symptoms that are non-specific to UTI:

Urgent microscopy and culture is the preferred method for diagnosing UTI, but for infants and children with an intermediate risk of serious illness, when this is not available, dipstick testing for

leucocytes and nitrite may be used.

Urine collection and testing: children 3 years and older

Perform a dipstick test for leukocyte esterase and nitrite.

If both are positive, start antibiotic treatment and if there is risk of serious illness and/or history of UTI, send a urine sample for culture.

If only nitrite is positive, start antibiotic treatment and send a urine sample for culture.

If only leukocyte esterase is positive, send a urine sample for microscopy and culture. Start antibiotic treatment for UTI only if there is good clinical evidence of UTI.

Determine location

Acute pyelonephritis/ upper urinary tract infection

•Bacteriuria and fever of 38°C or higher

•Bacteriuria, loin pain/tenderness and fever of less than 38°C

Cystitis/lower urinary tract infection

•Bacteriuria and symptoms or signs of UTI that are not systemic

History and examination: risk factors to identify

•Poor urine flow or dysfunctional voiding•Previously suggested or confirmed UTI•Recurrent fever of uncertain origin•Antenatally-diagnosed renal abnormality •Family history of vesicoureteric reflux or renal disease•Constipation•Dysfunctional voiding•Enlarged bladder•Abdominal mass•Evidence of spinal lesion•Poor growth•High blood pressure

Antibiotic treatment: infantsyounger than 3 months

•Refer immediately to paediatric specialist when UTI suspected

•The treatment is parenteral antibiotics in line with the NICE guideline ‘Feverish illness in children’ (clinical guideline 47)

Antibiotic treatment: infants and children

3 months and older

Acute pyelonephritis/upper urinary tract infection

•Consider referral to a paediatric specialist

•Treat with oral antibiotic, such as cephalosporin or co-amoxiclav, for 7-10 days

•If oral antibiotics cannot be used, give parenteral antibiotic treatment in line with the NICE guideline ‘Feverish illness in children’ (clinical guideline 47)

Antibiotic treatment: infants and children

3 months and olderCystitis/lower urinary tract infection

• Treat with oral antibiotics for 3 days

• Trimethoprim, nitrofurantoin, cephalosporin or amoxicillin may be suitable

• Re-assess if infant or child remains unwell after 24-48 hours. If no alternative diagnosis is made, send urine sample for culture to identify presence of bacteria and determine antibiotic sensitivity (if this has not already been done)

Antibiotic prophylaxis

Prophylactic antibiotics have been used on the assumption that they prevent further infections that may be associated with systemic illness and thus avoid subsequent renal damage. However, further evaluation is needed.

Antibiotic prophylaxis should not be routinely recommended following first-time UTI.

Imaging tests: recurrent UTI

The use of imaging will depend on the age of the child and on whether the UTI is recurrent or atypical.

Recurrent UTI is defined as:

• Two or more episodes of UTI with acute pyelonephritis/upper urinary tract infection, or

• One episode of UTI with acute pyelonephritis/upper urinary tract infection plus one or more episodes of UTI with cystitis/lower urinary tract infection, or

• Three or more episodes of UTI with cystitis/lower urinary tract infection

Imaging tests: atypical UTI

Atypical UTI is defined as any of the following:

• Seriously ill (for more information refer to ‘Feverish illness in children’ (NICE clinical guideline 47)

• 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.

ImagingRecommended imaging schedule for infants younger than 6 months

Test Responds well to treatment within 48 hours

Atypical UTI Recurrent UTI

Ultrasound during the acute infection

No Yes Yes

Ultrasound within 6 weeks

Yes No No

DMSA 4–6 months following the acute infection

No Yes Yes

MCUG No Yes Yes

Imaging

Test Responds well to treatment within 48 hours

Atypical UTI Recurrent UTI

Ultrasound during the acute infection

No Yes No

Ultrasound within 6 weeks

No No Yes

DMSA 4–6 months following the acute infection

No Yes Yes

MCUG No No No

Recommended imaging schedule for infants and children 6 months and older but younger than 3 years

ImagingRecommended imaging schedule for children 3 years and older

Test Responds well to treatment within 48 hours

Atypical UTI

Recurrent UTI

Ultrasound during the acute infection

No Yes No

Ultrasound within 6 weeks

No No Yes

DMSA 4–6 months following the acute infection

No No Yes

MCUG No No No

Implementation advice

Feedback to NICE suggests that there are likely to be four key areas for successful implementation:

• Diagnosis

• Training and equipment

• Communication

• Research and audit

Action plan: diagnosis

•Collaboration between microbiology laboratories, radiology departments and primary care teams will help to ensure that the guideline recommendations are integrated into all relevant protocols

•Put systems into place to prevent delays in the delivery of urine samples outside office hours

• If one does not already exist, set up a contract with microbiology services in which it is agreed that microscopy and culture will be performed outside office hours when necessary, and that GPs will be informed of the results via telephone

Action plan: training and equipment

•Ensure that the equipment and skills needed to collect and test urine samples are available in your setting

• Ensure that the equipment and skills needed to assess risk factors are available in your setting. If this is not possible, ensure there are alternative protocols for assessment of infants and children by a suitably trained professional

•Consider extending training in urgent microscopy to paediatric A&E staff

Action plan: communication

• Ensure that records are updated when there is confirmation of UTI, and that an alert mechanism is in place to indicate when an infant or child has been diagnosed with UTI in the past

• Ensure that care protocols include arrangements for follow-up of the results of urgent microscopy tests. Consider patient recall systems to facilitate prompt follow-up of patients whose urgent microbiology results indicate a need for treatment

Action plan: communication

• Review protocols to ensure that information is provided to parents and carers about the treatment and care of infants and children with UTI

•Work with colleagues to incorporate guideline changes into joint formularies between primary and secondary care

• Engage with your prescribing adviser to ensure that information on new prescribing is disseminated to pharmacists and to general practices

Action plan: research and audit

• Consider participating in pilot studies to tackle research recommendations highlighted in the guideline

•Consider participating in suitable audit projects to assess the effect of the guideline recommendations in practice  

•Incorporate the NICE audit criteria into local audit templates to ensure that prescribing protocols are fulfilled and to check whether UTI has been identified as lower or upper tract

Costs and savings

Recommendations with significant resource impact

Annual cost

£millions

Urine testing for infants and children aged under 3 years 3.1

Urine collection for infants and children aged under 3 yea 0.5

Urine testing for children aged 3 years and older - 0.7

Impact on referrals 1.3

Imaging tests - 3.4

Total net cost of implementing the urinary tract infection in children guideline 0.8

Resources from NICE

Implementation advice

Costing tools

•costing report•costing template

Audit criteria

www.nice.org.uk/CG54

Access the guideline online

Quick reference guide – a summary

NICE guideline – all of the recommendations

Full guideline – all of the evidence and rationale

‘Understanding NICE guidance’ – a version for patients and carers

www.nice.org.uk/CG54