Paediatric Acute care Guidelines PMH Emergency Department

Urinary tract infection (UTI) refers to a bacterial infection in the bladder (cystitis), or kidneys and ureters (pyelonephritis).

Background

  • Urinary tract infections in childhood are common and can be potentially serious in the first few years of life
  • The diagnosis of UTI should be considered in all febrile infants and young children, and in all infants with fever without focus

Assessment

  • A reliable urine specimen is vital to confirm the diagnosis – urine bags must not be used (high false positive rate)
  • Suprapubic aspiration is the gold standard in infants less than 6 months, however catheter specimens can be used.  In children over 6 months, catheter specimens are the preferred choice if a clean catch specimen has not been achieved by 45 minutes
  • In febrile young children who have a definite clear alternative clinical diagnosis, it is not necessary to check a urine collection in order to exclude a UTI

History

  • Fever may be present, particularly fever without apparent source
  • Irritability
  • Poor feeding
  • Vomiting
  • Jaundice (in neonates)
  • In older children symptoms can include dysuria, urinary frequency, and urinary incontinence

Investigations

  • Urinalysis – this is not accurate in infants under 12 months – so cannot be used to exclude a UTI. The only urinalysis results reliably predictive of a UTI are the leukocyte esterase and nitrites.
  • Urine should be sent to the laboratory for microscopy and culture. This must be done urgently in infants < 6 weeks of age in whom a UTI is suspected. After hours a microbiology technician will need to be called in after discussing with the on call Microbiologist.
  • A reliable urine specimen is vital to confirm the diagnosis – SPA, CSU, clean catch or MSU (in older kids)
  • Urine cultures may be negative if there is previous antibiotic treatment
  • Children who are systemically unwell and all infants < 3 mths should have blood tests including: FBC, blood cultures, CRP, U&E
  • Lumbar punctures should be done in neonates and children < 6 weeks

Investigations for age group

Birth to 6 weeks of age 6 weeks to 3 months of age Over 3 months of age
  • FBC, CRP, U&E, blood cultures
  • Urine – SPA
  • Lumbar puncture
  • FBC, CRP, U&E, blood culture
  • Urine – SPA best,  but can do catheter
  • Consider lumbar puncture only if toxic signs present

Toxic signs present:

  • FBC, CRP, U&E, blood cultures
  • Urine – SPA or catheter in children < 6 months, or catheter if you have waited for > 45 mins for a clean catch in older children
  • Consider lumbar puncture (if clinically indicated)

Appears unwell but no toxic signs:

  • Urine – SPA or catheter in children < 6 months, or catheter if you have waited for > 45 mins for a clean catch in older children

Appears well:

  • Urine – SPA or catheter in children < 6 months, or catheter if you have waited for > 45 mins for a clean catch in older children

Management

Management for age group

Refer to ChAMP Urinary Tract Infection Guideline 

Birth to 6 weeks of age 6 weeks to 3 months of age Over 3 months of age
  • Admit under General Paediatric Team
  • Intravenous antibiotics: Amoxycillin and Gentamicin
  • Admit under General Paediatric Team
  • Intravenous antibiotics: Amoxycillin and Gentamicin

Toxic signs present:

  • Admit under General Paediatric Team
  • Intravenous antibiotics: Amoxycillin and Gentamicin or Ceftriaxone

Appears unwell but no toxic signs:

  • Consider IM antibiotics: Gentamicin or Ceftriaxone
  • Discharge home on oral antibiotics: Cephalexin or Cotrimoxazole or Augmentin Duo
  • GP follow up in 48-72 hours to check urine culture and sensitivity
  • Request renal US based on child’s age as per referral instructions below

Appears well:

  • Discharge home on oral antibiotics: Cephalexin or Cotrimoxazole or Augmentin Duo
  • GP follow up in 48-72 hours to check urine culture and sensitivity
  • Request renal US based on child’s age as per referral instructions below

Medications

Oral antibiotic choices for patients who are being discharged from the Emergency Department include: 

Augmentin Duo 25mg/kg twice daily (to a maximum of 875mg of amoxycillin component)

        OR

Cotrimoxazole 4mg/kg twice daily(to a maximum dose of 160mg trimethoprim)

OR

Cephalexin 12.5mg/kg 6 hourly (maximum 500mg)

 The duration of treatment should be:

    • 5 days for children
    • 7 days if they are more unwell
    • 10 days for infants under 12 months

Intramuscular (IM) antibiotic choices for patients who are being discharged from the Emergency Department include: 

Gentamicin 6mg/kg (to a maximum of 480mg)

OR

Ceftriaxone 50mg/kg (maximum 2g)

Intravenous antibiotic choices for children being admitted to hospital include:

Amoxycillin 50mg/kg 6 hourly (maximum 1g) plus Gentamicin 7.5mg/kg (< 10 years old) or 6mg/kg (>10 years old) (maximum 480mg)

OR

Ceftriaxone 50mg/kg once daily  (maximum 2g) – if penicillin allergy

See UTI: ChAMP Empiric Guideline for further information.
Prophylaxis is not routinely used after the first documented UTI.

Referrals and follow up

Renal Tract Ultrasounds:

  • All children <3 yrs presenting with a first UTI should have a renal tract US
  • A renal tract ultrasound is not always necessary for children aged 3 years or older with a simple UTI, however:
    • Children of any age with recurrent urinary tract infections should have a renal tract ultrasound (non urgent)
    • Children any age with an atypical UTI or UTI responding poorly to treatment should have a renal tract ultrasound (urgent)  

GP Follow Up:

  • All children presenting with a UTI should have a GP follow up and a GP letter completed (see UTI GP Letter).
  • In children > 6 mths, GP will arrange an outpatient renal tract US

Referral to General Paediatric Team:

  • Infants ≤ 6 mths presenting with a UTI should be referred to the General Paediatric Outpatient Clinic at PMH. Complete an internal referral form.
  • A PMH radiology request form should be completed for a renal tract US, and this placed with the Outpatient Clinic referral form in the ED Consultant’s office. The Consultant checking results will send these off if a UTI is proven on culture.

Advise parents if the US is abnormal, the General Paediatric Team will arrange a clinic follow up.

Management Paperwork

References

  1. WA Health Child and Adolescent Health Service. Department of General Paediatrics. Urinary Tract Infections: Investigation and Follow Up Clinical Practice Guideline. Version 1: 2015

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