Managing UTIs in children
Diagnosing and managing children with urinary tract infections (UTis) present challenges for GPs, and there is wide variation in clinical practice.1 This is a cause of concern, particularly because of the prevalence of these infections – 3.6% in boys and 11.3% in girls – and the fact that 4.5% of diagnosed patients may develop renal scarring.2 Until now, guidance has tended to focus on imaging and follow up, offering little support for GPs in the key elements of care.3
A recent NICE guideline, however, offers some signposts through this difficult clinical area.4 Urinary tract infection in children: diagnosis, treatment and long-term management builds on PRODIGY recommendations to give practical suggestions for when UTI should be suspected and on the clinical approach to take.5
Previous guidance stratified management into infants, children under seven years, and older children.3 The NICE guideline describes the symptoms and signs in babies younger than three months, and in infants and children three months and older; while diagnostic criteria and investigations are specified for babies younger than three months (six months for imaging); three months or older but younger than three years; and three years and older.
The guideline recommends that clinicians differentiate between pyelonephritis and lower urinary tract infections; fever 38°C or higher, or lower than this with loin pain and bacteriuria, are important indicators of pyelonephritis.
The guideline emphasises the need to consider UTI as a possible diagnosis in a child who is unwell.
Non-specific signs and symptoms predominate in infants younger than three months, and all children may have fever, but specific symptoms are more frequent in older children. The new guideline endorses earlier NICE recommendations on feverish illness in children, which advise urgent referral to a paediatric specialist for any infant younger than three months with a suspected UTI.6
There is practical advice on urine testing. GPs should arm themselves with testing sticks for nitrites and leucocytes; blood alone, either its presence or absence, is not a reliable indicator. Nitrites are more specific than leucocytes for UTI; however, if either is present or there are other strong suspicions, particularly in children younger than three years, urine should be sent for microbiology. A clean catch sample is best, but an alternative is to use a collecting pad.
The distinction between upper and lower tract infections is important when deciding on an antibiotic and length of treatment. More potent antibiotics and longer courses are needed when pyelonephritis is suspected; three-day courses of ‘routine' urinary antibiotics are the rule for lower tract infections.
GPs are no longer expected to refer all children who present with UTI. It is logical for us to investigate uncomplicated UTI, that is, a suspected E. coli infection of the lower tract and a first episode. In these circumstances, infants younger than six months should have a urinary ultrasound within six weeks, but for older children routine ultrasound is not recommended.
Depending on the GP's clinical confidence, children with complicated or recurrent UTI could undergo imaging according to the guideline without specialist paediatric involvement. However, my view is that specialist advice should be sought if abnormalities such as vesicoureteric reflux or renal scarring are found.
The new guideline will support GPs in taking a greater role in managing children with UTI and enable us to give more definitive advice to parents, carers and children when mapping out management. It should also reduce unnecessary investigations and referrals.
NICE clinical guideline 54. Urinary tract infection in children: diagnosis, treatment and long-term management can be downloaded free of charge from the NICE website: www.nice.org.uk.
Dr Peter Saul
MB ChB, DCH, MRCGP, DRCOG
GP, Wrexham and hospital practitioner in paediatrics