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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

Assess the symptoms and signs Test urine when an infant or child presents with:

unexplained fever of 38C 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

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

Presenting symptoms and signs in infants and children with UTI

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 years
If 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 nonspecific 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 Bacteriuria and fever of 38C or higher pyelonephritis/ upper urinary tract Bacteriuria, loin pain/tenderness and fever of less infection than 38C
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: infants younger 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 older


Cystitis/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.

Imaging
Recommended imaging schedule for infants younger than 6 months
Test Responds well to treatment within 48 hours No Yes Atypical UTI Recurrent UTI

Ultrasound during the acute infection Ultrasound within 6 weeks

Yes No

Yes No

DMSA 46 months No following the acute infection


MCUG No

Yes

Yes

Yes

Yes

Imaging
Recommended imaging schedule for infants and children 6 months and older but younger than 3 years
Test Responds well to Atypical UTI treatment within 48 hours No No No Yes No Yes Recurrent UTI No Yes Yes

Ultrasound during the acute infection Ultrasound within 6 weeks DMSA 46 months following the acute infection MCUG

No

No

No

Imaging
Recommended imaging schedule for children 3 years and older
Test Responds well to treatment within 48 hours No No No Atypical UTI Yes No No Recurrent UTI No Yes Yes

Ultrasound during the acute infection Ultrasound within 6 weeks DMSA 4 6 months following the acute infection 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
Urine testing for infants and children aged under 3 years Urine collection for infants and children aged under 3 yea Urine testing for children aged 3 years and older Impact on referrals Imaging tests

Annual cost millions


3.1 0.5 - 0.7 1.3 - 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

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