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Primary care management and referral guideline Primary care management and referral guideline

Urinary Tract Infection (UTI) in children and adolescents – Management and referral guideline

Red flags

  • Child aged < 3 months
  • Known urinary tract anomaly or neurogenic bladder
  • Kidney transplant recipient

Purpose

Referral and management guidelines contain condition-based information for GPs about when to refer a patient, assessment and management measures that should be taken prior to submitting a referral, and what should be included in a referral to the relevant outpatient department or specialist service.

Introduction

  • Urinary tract infections (UTIs) are common in children but may be difficult to recognise because the presenting symptoms or signs are often non-specific. A child with a diagnosed UTI has about a 1 in 5 chance of having a recurrent UTI.
  • Girls are more commonly affected than boys, except in the first few months of life.
  • Most UTIs are caused by E. coli. Culture of unusual organisms may indicate underlying pathology.
  • Optimal urine collection is important for the diagnosis of UTIs.

Assessment

Take an age-appropriate history, and suspect UTI in:

  • children aged < 3 years with unexplained fever.
  • any patient with symptoms of UTI, especially if risk factors present.

Symptoms of UTI

  • Unexplained fever
  • Lethargy, irritability, poor feeding
  • Dysuria, frequency, urgency, or new incontinence
  • Abdominal, or suprapubic, or loin pain or discomfort
  • Vomiting
  • Haematuria or offensive urine

Risk factors for UTI

  • Constipation
  • Previous UTI
  • Known urinary tract anomaly or neurogenic bladder
  • Family history of recurrent UTI, vesicoureteral reflux, or other urinary tract disease
  • Urinary catheter
  • Sexually active adolescent

Perform an age-appropriate examination:

  • Check general appearance/alertness/hydration status, and vital signs. Determine if the patient is seriously ill.
  • Record height and weight, and plot in an appropriate growth chart – available in most general practice software.
  • Check abdomen for tenderness, palpable masses (e.g., renal, bladder, faecal mass), distension, loin tenderness on percussion.
  • Consider checking genital area e.g., for balanitis, phimosis, vulvovaginitis. If performing genital-anal examination, follow recommended protocol and consider a chaperone.

Recommended protocol

  • Only perform a genital examination if there is a specific and clear clinical indication.
  • Always seek voluntary consent from the parent or guardian, and the child or young person.
    • Explain the purpose of the examination and only proceed if the child or young person consents. Do not proceed if the child refuses to cooperate.
    • Consider capacity to consent of patients who are physically, mentally, or intellectually impaired, and those of culturally or linguistically diverse background (amongst others).
  • Always consider:
    • the presence of a chaperone in the room. Adolescents are entitled to decline this, and the doctor may decline conducting the examination if a chaperone is declined by the patient.
    • needs of infants and younger children – allow the parent or guardian to remain close to the child or hold the child on their lap during the examination.
    • needs of older children and adolescents – allow them to undress or dress in private and wear a gown for the examination.
    • the patient’s specific needs, e.g. if disabled or of culturally or linguistically diverse background.
  • If relevant, discuss and explain limits of confidentiality with adolescents.

Consider other causes of urinary symptoms

Other causes of urinary symptoms in children

  • Diabetes – always check blood glucose level if patient with frequency, polyuria, or nocturia.
  • Balanitis – redness of meatus will be evident.
  • Vulvovaginitis – soapy baths are a risk factor for vulvovaginitis in young girls.
  • Chlamydia or other STI – consider STI screening in sexually active teens, and see Sexual Health Check pathway.
  • Glomerulonephritis – suspect if painless haematuria.
  • Urolithiasis.

Arrange investigations:

  • Urine – collect an adequate urine sample before starting antibiotic treatment:

    Adequate urine sample

    • In infants and younger children, clean the perineal/genital area with water or saline and pat dry.
      • Collect a midstream specimen of urine (MSU) in patients able to void on request.
      • In younger (pre-continent) children, collect a clean catch specimen.
        Clean catch urine specimen
        Leave the baby exposed and catch the mid-part of the urine stream in a sterile urine container. The specimen jar must not touch the penis or perineum.
        Gentle bladder percussion or suprapubic stimulation with a cool wet compress can sometimes help.
    • If unable to collect a clean catch specimen (e.g., infant aged < 6 months):
      • consider a bag urine collection, or
        Bag urine collection
        Bag urine collection is generally not recommended, given high contamination rates.
        Consider only in clinically stable infants where a clean catch collection is not possible.
        For collection, cleanse the genital area with normal saline or tap water, and pat dry. Apply the bag by placing the adhesive over the vulva or penis.
      • Discuss with your local paediatric team or arrange transfer to your nearest ED as appropriate for investigation and management
    • Use urine dipstick test to guide initial management, and send sample for microscopy, culture, and sensitivity (urine MCS).
    • If sexually active adolescent, consider STI risk, and request chlamydia trachomatis PCR. See Sexual Health Check pathway.

    Try to ensure urine is tested within 4 hours. Make sure the sample is kept refrigerated from collection through to pathology pick-up.

  • Imaging – consider indications for imaging. Note that imaging is not routinely indicated at time of diagnosis, but may need to be requested at follow-up.
    Indications for imaging
    Consider requesting a renal and bladder ultrasound in children with:

    • Complicated UTI

      Complicated UTI

      • Pyelonephritis
      • Bacteraemia
      • Renal impairment
      • Aged < 6 months at time of first febrile UTI
      • Urine culture with atypical organisms (e.g., Staphylococcus aureus, Pseudomonas)
      • Lack of clinical response to 48 hours of antibiotic if sensitive organism
      • Abdominal mass
      • Poor urinary stream
    • recurrent UTI – consider recurrent UTI if second episode of confirmed bacteriuria and fever.

    Do not request micturating cystourethrogram (MCUG) or dimercaptosuccinic acid scan (DMSA) in primary care unless advised by specialist.

Make a diagnosis:

  • Do not diagnose UTI based on:
    • dipstick examination alone (i.e., leucocyte esterase or nitrite).
    • leucocyturia without bacteriuria.
    • asymptomatic bacteriuria.
  • Consider UTI if positive culture and associated symptoms.
  • Consider pyelonephritis in children if bacteriuria and fever with or without loin tenderness.

Management

Discuss with your local paediatric team on call or arrange transfer to your nearest ED as appropriate if:

  • Red flags

    Red flags

    • Child aged < 3 months
    • Known urinary tract anomaly or neurogenic bladder
    • Kidney transplant recipient
  • patient seriously ill or unable to tolerate oral medications.

If you are in the QCH catchment, contact CATCH.

If patient is aged < 3 months, there is a higher risk of serious secondary infection. Septic work-up and treatment with parenteral antibiotics may be indicated.

If patient with suspected UTI and positive dipstick test (i.e., leucocyte esterase- or nitrite-positive), start presumptive antibiotic treatment (note that dipstick examination may be falsely negative in early infection, or in newborns and young infants):

Presumptive antibiotic treatment
Use one of:

  • Trimethoprim and sulphamethoxazole (8 mg + 40 mg/mL), 4 mg + 20 mg/kg = 0.5 mL/kg (up to 20 mL) per dose, orally, twice a day, or
  • Cephalexin 25 mg/kg (up to 750 mg) per dose, orally, three times a day, or
  • Augmentin (amoxycillin/clavulanate) 22.5 mg of amoxicillin/kg (up to 875 mg of amoxicillin) per dose, orally, twice a day, or
  • Trimethoprim 4 mg/kg (up to 150 mg) per dose, orally, twice a day (no paediatric liquid formulation available in Australia).
  • If bag-collected sample, check additional considerations.

    Additional considerations for bag-collected sample

    • A negative dipstick examination (i.e., leucocyte esterase- and nitrite-negative) of a bag-collected sample makes UTI less likely.
    • A positive dipstick examination of a bag-collected sample should generally be followed by an adequate sample collection being sent for MCS. On a case by case basis, consider:
      • observing the patient in the practice until a clean catch sample can be collected and tested.
      • initiating presumptive treatment and sending bag-collected sample for MCS if:
        • unable to collect clean catch specimen, and
        • access to specialist service not readily available, or
        • patient with high probability of UTI (e.g., risk factors including recurrent UTIs).
      • requesting collection via a transurethral catheter or suprapubic aspiration before initiating treatment – consider discussing with your local paediatric team or arranging transfer to your nearest ED as appropriate for investigation and management
  • If patient clinically stable and suspected pyelonephritis (i.e., bacteriuria and fever with or without loin tenderness/pain), treat for 7 to 10 days.
  • If patient with lower urinary tract infection (i.e., bacteriuria and lower urinary tract symptoms without fever), treat for 2 to 4 days.

Arrange review at 48 hours:

  • Check urine culture and sensitivities, and adjust antibiotic treatment accordingly.
  • If patient not improving despite adequate antibiotic therapy, discuss with your local paediatric team
  • Consider indications for imaging and arrange accordingly.
    Indications for imaging
    Consider requesting a renal and bladder ultrasound in children with:

    • complicated UTI.

      Complicated UTI

      • Pyelonephritis
      • Bacteraemia
      • Renal impairment
      • Aged < 6 months at time of first febrile UTI
      • Urine culture with atypical organisms (e.g., Staphylococcus aureus, Pseudomonas)
      • Lack of clinical response to 48 hours of antibiotic if sensitive organism
      • Abdominal mass
      • Poor urinary stream
    • recurrent UTI – consider recurrent UTI if second episode of confirmed bacteriuria and fever.

    Do not request micturating cystourethrogram (MCUG) or dimercaptosuccinic acid scan (DMSA) in primary care unless advised by specialist.

Refer to your local General Paediatrics service if not under specialist care already, and:

  • complicated UTI

    Complicated UTI

    • Pyelonephritis
    • Bacteraemia
    • Renal impairment
    • Aged < 6 months at time of first febrile UTI
    • Urine culture with atypical organisms (e.g., Staphylococcus aureus, Pseudomonas)
    • Lack of clinical response to 48 hours of antibiotic if sensitive organism
    • Abdominal mass
    • Poor urinary stream
  • recurrent UTI.
  • suspected or confirmed anatomical abnormality on renal ultrasound (including renal pelvic dilatation).

Preventing recurrence

Do not routinely prescribe antibiotic prophylaxis in children with recurrent UTI. Discuss with your local paediatric team

  • on a case by case basis e.g., high grade vesicoureteral reflux (VUR).
  • Consider seeking advice from your local paediatric surgical team regarding circumcision for boys with high grade VUR and recurrent UTIs.

    Circumcision

    • Routine circumcision is not recommended in Australia and certainly not in infants aged < 6 months.
    • Circumcision may need to be considered in cases of severe phimosis (and related conditions), refractory to steroid therapy, and for religious reasons.
  • Identify and manage contributing factors.

    Contributing factors

    • Actively seek and manage constipation.
    • Discuss hygiene and wiping after bowel motions.
    • Encourage good fluid intake and regular voiding (e.g., 3 hourly).
    • Discourage bubble baths in young girls.
  • Do not recommend therapies of no proven benefit.

    Therapies of no proven benefit

    • Cranberry juice
    • Probiotics
    • Vitamin A
    • Horseradish
    • UroVaxom
  • Give patient information sheet – Sydney Children’s Hospitals Network – Urinary Tract Infection in Children Fact Sheet.
  • If any concerns, seek discuss with your local paediatric team

When to refer

  • Discuss with your local paediatric team on call or arrange transfer to your nearest ED as appropriate if:
    • red flags

      Red flags

      • Child aged < 3 months
      • Known urinary tract anomaly or neurogenic bladder
      • Kidney transplant recipient
    • patient seriously ill or unable to tolerate oral medications.

    If you are in the QCH catchment, contact CATCH.

  • Consider discussing with your local paediatric team or arrange transfer to your nearest ED as appropriate if patient requiring urine collection via a transurethral catheter or suprapubic aspiration before initiating treatment.
  • Refer to your local General Paediatrics service if:
    • complicated UTI.
    • recurrent UTI.
    • suspected or confirmed anatomical abnormality on renal ultrasound (including renal pelvic dilatation).
  • Discuss with your local paediatric team if:
    • patient not improving despite adequate antibiotic therapy.
    • considering prophylactic antibiotics.
    • any other concerns.
  • Consider seeking advice from your local paediatric surgical team if considering circumcision for children with high grade VUR and recurrent UTI.

Referring to your local Paediatric services

Public

Check the patient’s catchment area before requesting assessment. When services are available in the patients local area, refer the patient to the local hospital.

Queensland Children’s Hospital

1. Referral can be made by either:

  • GP Smart Referral via BP or Medical Director
  • Secure messaging
    Secure messaging
    Send a written request to the Referral Centre via eReferral
    (Medical Objects ID: RQ402900084, HealthLink ID: qldrchld):

    • To download templates, see Referral Forms.
    • If unable to attach investigations or use secure messaging, fax to 1300 407 281.

    For more information, contact the Referral Centre:
    P.O. Box 3474, South Brisbane QLD 4101
    Phone 1300 762 831
    Fax 1300 407 281

2. Check the minimum referral criteria and insert the required information into referral.

Private

Search for a provider via the National Health Services Directory.

Guideline approval and disclaimer

Guideline approval history
Version no. 1.0 Approval date 03/09/2018 Review date 01/09/2021

Disclaimer

The information contained in this GP referral and management guideline is intended for information purposes only. The information has been prepared using a multidisciplinary approach with reference to the best information and evidence available at the time of preparation. No assurance is given that the information is entirely complete, current, or accurate in every respect.
This guideline is not a substitute for clinical judgement, knowledge and expertise, or medical advice. Variation from this guideline, taking into account individual circumstances may be appropriate.
This guideline does not address all elements of standard practice and accepts that individual clinicians are responsible for the following:
  • ●  Providing care within the context of locally available resources, expertise, and scope of practice.
  • ●  Supporting consumer rights and informed decision making in partnership with healthcare practitioners including the right to decline intervention or ongoing management.
  • ●  Advising consumers of their choices in an environment that is culturally appropriate and which enables comfortable and confidential discussion. This includes the use of interpreter services where necessary.
  • ●  Ensuring informed consent is obtained prior to delivering care.
  • ●  Meeting all legislative requirements and professional standards.
  • ●  Applying standard precautions, and additional precautions as necessary, when delivering care.
  • ●  Documenting all care in accordance with mandatory and local requirements.
Children’s Health Queensland disclaims, to the maximum extent permitted by law, all responsibility and all liability (including without limitation, liability in negligence) for all expenses, losses, damages and costs incurred for any reason associated with the use of this guideline, including the materials within or referred to throughout this document being in any way inaccurate, out of context, incomplete or unavailable.

Resources

For health professionals

For families

Parent service

Paediatric Surgery and Urology

Contact details

Hospital Switchboard
(Ask for the General Paediatric Registrar)
t: 07 3068 1111

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