Urinary Tract Infection (UTI) in Children

Comments from Expert Advisory Committee

UTI in children is an illness caused by infection of the lower urinary tract (cystitis), the upper urinary tract (pyelonephritis) or both.

Upper UTI (pyelonephritis) is diagnosed in children presenting with:

Fever ≥38⁰C and bacteriuria
Fever <38⁰C, loin pain/tenderness and bacteriuria

Lower UTI (cystitis) is diagnosed in children with:

Bacteriuria and localised symptoms including lower abdominal or suprapubic pain, dysuria, urinary frequency and urgency
No systemic symptoms or signs.

Symptoms/signs of a UTI in children <3 months include:

Fever
Vomiting
Lethargy
Irritability
Poor feeding and failure to thrive

Symptoms/signs of a UTI in children ≥3 months include:

As above (fever, vomiting, lethargy, irritability, poor feeding)
plus
Abdominal pain, or,
Loin tenderness

Hospital referral:

Refer unwell infants under 3 months for urgent assessment
Refer infants <6 months to a paediatrician for follow-up.
Refer children <3 years post atypical or recurrent UTI for imaging

Investigations:

Have a low threshold for testing urine of unwell children who are less than 3 years.
Perform urine dipstick in children ≥3 months with symptoms/signs of a UTI.
To help attain a clean catch sample it may be useful to apply gentle circular stimulation of the suprapubic of the child with gauze soaked in cold water.
If a clean catch urine sample is not possible, a nappy pad sample is a viable alternative for dipstick testing.
- If there is a positive dipstick from a nappy pad try hard to get a clean catch sample.
- A nappy pad sample is not suitable for formal laboratory testing as culture results are unreliable and local laboratory may not accept such samples

*Adapted from NICE Guidance on Management of UTI in Children (CG54)

Dipstick result on sample <4 hours old	Action
Children 3 months-3 years
Leukocyte positive +/- nitrite positive	Probable UTI: Send MSU Start antibiotics
Leukocyte and nitrite negative	Unlikely UTI: Do not send MSU unless: Suspected upper UTI or pyelonephritis High/medium risk of serious illness Recurrent UTI When clinical symptoms and dipstick results don’t correlate. Do not start antibiotics
Children over 3 years
Leukocyte and nitrite positive	Probable UTI: Send MSU IF: Child is at intermediate/high risk of serious illness, AND/OR Previous history of UTI. Start antibiotics
Leukocyte negative and nitrite positive	Possible UTI: Send MSU if clinically suspicious of UTI and urine sample was fresh. Consider starting antibiotics pending MSU result.
Leukocyte positive and nitrite negative	Possible UTI: Send MSU Do not start antibiotics unless clinical evidence of UTI (leukocytes may indicate infection elsewhere).
Leukocyte negative and nitrite negative	Unlikely UTI so explore other causes Do not send MSU Do not start antibiotics

The presence of pyuria and symptoms distinguishes UTI from asymptomatic bacteriuria

Refer children <3 years post atypical or recurrent UTI for imaging.
Atypical urinary infection includes any of the following:

Failure to respond after 48h appropriate antibiotic treatment.
Poor urine flow.
Bladder or abdominal mass.
Infection with non E. coli organism.
Sepsis.
Abnormal renal function on blood tests.

Recurrent urinary infection:

≥1 episode of upper tract infection/pyelonephritis and ≥1 episode of lower tract infection OR
≥2 episodes of upper tract infection/pyelonephritis OR
≥3 episodes of lower urinary tract infection or cystitis.

View the paediatric algorithm on Urinary Tract Infection

Treatment

Choice of empirical therapy should be governed by local resistance rates where available. Patterns can vary substantially across the country.

Upper UTI in Children

Upper UTI in Children
Drug	Dose	Duration	+/- Notes
1st choice option
Cefalexin	See dosing table	7-10 days
2nd choice option
Co-amoxiclav	See dosing table	7-10 days

Do not send a “test of cure” MSU if child has had a good clinical response to antibiotic therapy.

Lower UTI in Children

Lower UTI in Children
Drug	Dose	Duration	+/- Notes
1st choice option
Trimethoprim*	See dosing table	3 days
Nitrofurantoin*	See dosing table	3 days	Nitrofurantoin liquid is an unlicensed product. Please contact community pharmacist to discuss availability.
Cefalexin	See dosing table	3 days

*safe in penicillin allergy

Do not send a “test of cure” MSU if child has had a good clinical response to antibiotic therapy.

Patient Information

Visit HPSC Information Leaflets pages for the General Public, (MRSA, CRE, etc)

We recommend patients use the website developed by HSE/ICGP/IPU partnership www.undertheweather.ie for tips on how to get better from common infections without using antibiotics, what you can do for yourself or a loved one and when to seek help.

Safe Prescribing (visit the safe prescribing page)

Doses are oral and for adults unless otherwise stated
Dosing in children quick reference dosage/weight guide
Clarithromycin and other macrolides warning
Penicillin allergy – tips on prescribing in penicillin allergy
Renal impairment dosing table
Drug interactions table. Extensive drug interactions for clarithromycin, fluoroquinolones, azole antifungals and rifampicin. Many antibiotics increase the risk of bleeding with anticoagulants.
Visit the Health Products Regulatory Authority (HPRA) website for detailed drug information (summary of product characteristics and patient information leaflets). Dosing details, contraindications and drug interactions can also be found in the Irish Medicines Formulary (IMF) or other reference sources such as British National Formulary (BNF) / BNF for children (BNFC).
- Weight-based dosing for Paracetamol in Children PDF 785.3 KB
- Weight-based dosing for Ibuprofen in Children PDF 781.7 KB

Reviewed July 2022