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1 Urinary tract infection in under 16s: diagnosis

2 and management
3 NICE guideline: short version
4 Draft for consultation, June 2017
5

This guideline covers diagnosing and managing first or recurrent upper or lower
urinary tract infection in infants, children and young people. It aims to achieve
more consistent clinical practice, based on accurate diagnosis and effective
management.

Who is it for?

 Healthcare professionals
 Commissioners
 People under 16 with urinary tract infection, their families and carers

This guideline will update NICE guideline CG54 (published August 2007).

We have updated the recommendations on the urine testing strategies for infants
and children under 3 years.

You are invited to comment on the new and updated recommendations in this
guideline. These are marked as:

 [2017]
You are also invited to comment on recommendations that NICE proposes to
delete from the 2007 guideline.

We have not updated recommendations shaded in grey, and cannot accept

comments on them.

See Update information for a full explanation of what is being updated.

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This version of the guideline contains the draft recommendations, context and
recommendations for research. Information about how the guideline was
developed is on the guideline’s page on the NICE website. This includes details of
the committee and any declarations of interest.

The supporting information and evidence for the 2017 recommendations is

contained in the addendum. The supporting information and evidence for the 2007
recommendations is in the full version of the 2007 guideline.

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1 Contents
2
3 Recommendations ..................................................................................................... 3
4 1.1 Diagnosis ...................................................................................................... 4
5 1.2 Acute management ....................................................................................... 9
6 1.3 Imaging tests ............................................................................................... 11
7 1.4 Surgical intervention .................................................................................... 14
8 1.5 Follow-up .................................................................................................... 14
9 1.6 Information and advice for children, young people and parents or carers ... 15
10 Putting this guideline into practice ............................................................................ 16
11 Context ..................................................................................................................... 18
12 Recommendations for research ............................................................................... 19
13 Update information ................................................................................................... 21

14 Recommendations
People have the right to be involved in discussions and make informed
decisions about their care, as described in your care.

Making decisions using NICE guidelines explains how we use words to show
the strength (or certainty) of our recommendations, and has information about
prescribing medicines (including off-label use), professional guidelines,
standards and laws (including on consent and mental capacity), and
safeguarding.

15 1.1 Diagnosis

16 1.1.1 Symptoms and signs

17 1.1.1.1 Infants and children presenting with unexplained fever of 38°C or higher
18 should have a urine sample tested within 24 hours. [2007]

19 1.1.1.2 Infants and children with an alternative site of infection should not have a
20 urine sample tested. When infants and children with an alternative site of

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1 infection remain unwell, urine testing should be considered after 24 hours

2 at the latest. [2007]

3 1.1.1.3 Infants and children with symptoms and signs suggestive of urinary tract
4 infection (UTI) should have a urine sample tested for infection. Table 1 is
5 a guide to the symptoms and signs that infants and children present with.
6 [2007]

7 Table 1 Presenting symptoms and signs in infants and children with UTI
Age group Symptoms and signs
Most common ------------------> Least common
Infants younger than Fever Poor feeding Abdominal pain
3 months Vomiting Failure to thrive Jaundice
Lethargy Haematuria
Irritability Offensive urine
Infants Preverbal Fever Abdominal pain Lethargy
and Loin tenderness Irritability
children,
Vomiting Haematuria
3 months
or older Poor feeding Offensive urine
Failure to thrive
Verbal Frequency Dysfunctional voiding Fever
Dysuria Changes to Malaise
continence Vomiting
Abdominal pain Haematuria
Loin tenderness Offensive urine
Cloudy urine
8

9 1.1.2 Assessment of risk of serious illness

10 1.1.2.1 The illness level in infants and children should be assessed in accordance
11 with recommendations in the NICE guideline on fever in in under 5s.
12 [2007]

13 1.1.3 Urine collection

14 1.1.3.1 A clean catch urine sample is the recommended method for urine
15 collection. If a clean catch urine sample is unobtainable:

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1  Other non-invasive methods such as urine collection pads should be

2 used. It is important to follow the manufacturer's instructions when
3 using urine collection pads. Cotton wool balls, gauze and sanitary
4 towels should not be used to collect urine in infants and children.
5  When it is not possible or practical to collect urine by non-invasive
6 methods, catheter samples or suprapubic aspiration (SPA) should be
7 used.
8  Before SPA is attempted, ultrasound guidance should be used to
9 demonstrate the presence of urine in the bladder. [2007]

10 1.1.3.2 In an infant or child with a high risk of serious illness it is highly preferable
11 that a urine sample is obtained; however, treatment should not be delayed
12 if a urine sample is unobtainable. [2007]

13 1.1.4 Urine preservation

14 1.1.4.1 If urine is to be cultured but cannot be cultured within 4 hours of collection,

15 the sample should be refrigerated or preserved with boric acid
16 immediately. [2007]

17 1.1.4.2 The manufacturer's instructions should be followed when boric acid is

18 used to ensure the correct specimen volume to avoid potential toxicity
19 against bacteria in the specimen. [2007]

20 1.1.5 Urine testing

21 1.1.5.1 For all diagnostic tests there will be a small number of false negative
22 results; therefore clinicians should use clinical criteria for their decisions in
23 cases where urine testing does not support the findings. [2007]

24 1.1.5.2 Refer all infants under 3 months with a suspected UTI (see table 1) to
25 paediatric specialist care, and

26  send a urine sample for urgent microscopy and culture

27  manage in line with the NICE guideline on fever in under 5s. [2017]

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1 1.1.5.3 Use dipstick testing for infants and children 3 months or older but younger
2 than 3 years with suspected UTI.

3  If both leukocyte esterase and nitrite are negative: do not start antibiotic
4 treatment; do not send a urine sample for microscopy and culture
5 unless at least 1 of the criteria in recommendation 1.1.6.1 apply.
6  If leukocyte esterase or nitrite, or both are positive: start antibiotic
7 treatment; send a urine sample for microscopy and culture. [2017]

8 1.1.5.4 The urine-testing strategy shown in table 2 is recommended for children

9 aged 3 years or older1. [2007]

10 1.1.5.5 Follow the guidance in table 3 on interpreting microscopy results. [2007]

1 Assess the risk of serious illness in line with the NICE guideline on fever in under 5s to ensure
appropriate urine tests and interpretation, both of which depend on the child’s age and risk of serious
illness.

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1 Table 2 Urine-testing strategies for children 3 years or older

Dipstick testing for leukocyte esterase and nitrite is diagnostically as useful as
microscopy and culture, and can safely be used.
If both leukocyte The child should be regarded as having UTI and
esterase and nitrite are antibiotic treatment should be started. If a child has a
positive high or intermediate risk of serious illness and/or a past
history of previous UTI, a urine sample should be sent for
culture.
If leukocyte esterase is Antibiotic treatment should be started if the urine test was
negative and nitrite is carried out on a fresh sample of urine. A urine sample
positive should be sent for culture. Subsequent management will
depend upon the result of urine culture.
If leukocyte esterase is A urine sample should be sent for microscopy and
positive and nitrite is culture. Antibiotic treatment for UTI should not be started
negative unless there is good clinical evidence of UTI (for
example, obvious urinary symptoms). Leukocyte
esterase may be indicative of an infection outside the
urinary tract which may need to be managed differently.
If both leukocyte The child should not be regarded as having UTI.
esterase and nitrite are Antibiotic treatment for UTI should not be started, and a
negative urine sample should not be sent for culture. Other causes
of illness should be explored.

2 Table 3 Guidance on the interpretation of microscopy results

Microscopy results Pyuria positive Pyuria negative
Bacteriuria positive The infant or child should The infant or child should
be regarded as having UTI be regarded as having UTI
Bacteriuria negative Antibiotic treatment should The infant or child should
be started if clinically UTI be regarded as not having
UTI

3 1.1.6 Indication for culture

4 1.1.6.1 Urine samples should be sent for culture:

5  in infants and children who are considered to have acute

6 pyelonephritis/upper urinary tract infection (see 1.1.8.1)
7  in infants and children with a high to intermediate risk of serious illness
8  in infants under 3 months
9  in infants and children with a positive result for leukocyte esterase or
10 nitrite
11  in infants and children with recurrent UTI
12  in infants and children with an infection that does not respond to
13 treatment within 24–48 hours, if no sample has already been sent

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1  when clinical symptoms and dipstick tests do not correlate. [2017]

2 1.1.7 History and examination on confirmed UTI

3 1.1.7.1 The following risk factors for UTI and serious underlying pathology should
4 be recorded:

5  poor urine flow

6  history suggesting previous UTI or confirmed previous UTI
7  recurrent fever of uncertain origin
8  antenatally diagnosed renal abnormality
9  family history of vesicoureteric reflux (VUR) or renal disease
10  constipation
11  dysfunctional voiding
12  enlarged bladder
13  abdominal mass
14  evidence of spinal lesion
15  poor growth
16  high blood pressure. [2007]

17 1.1.8 Clinical differentiation between acute pyelonephritis/upper urinary

18 tract infection and cystitis/lower urinary tract infection

19 1.1.8.1 Infants and children who have bacteriuria and fever of 38°C or higher
20 should be considered to have acute pyelonephritis/upper urinary tract
21 infection. Infants and children presenting with fever lower than 38°C with
22 loin pain/tenderness and bacteriuria should also be considered to have
23 acute pyelonephritis/upper urinary tract infection. All other infants and
24 children who have bacteriuria but no systemic symptoms or signs should
25 be considered to have cystitis/lower urinary tract infection. [2007]

26 1.1.9 Laboratory tests for localising UTI

27 1.1.9.1 C-reactive protein alone should not be used to differentiate acute

28 pyelonephritis/upper urinary tract infection from cystitis/lower urinary tract
29 infection in infants and children. [2007]

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1 1.1.10 Imaging tests for localising UTI

2 1.1.10.1 The routine use of imaging in the localisation of a UTI is not

3 recommended. [2007]

4 1.1.10.2 In the rare instances when it is clinically important to confirm or exclude

5 acute pyelonephritis/upper urinary tract infection, power Doppler
6 ultrasound is recommended. When this is not available or the diagnosis
7 still cannot be confirmed, a dimercaptosuccinic acid (DMSA) scintigraphy
8 scan is recommended. [2007]

9 1.2 Acute management

10 Note that the antibiotic requirements for infants and children with conditions that are
11 outside the scope of this guideline (for example, infants and children already known
12 to have significant pre-existing uropathies) have not been addressed and may be
13 different from those given here.

14 1.2.1.1 Infants and children with a high risk of serious illness should be referred
15 urgently to the care of a paediatric specialist. [2007]

16 1.2.1.2 Infants younger than 3 months with a possible UTI should be referred
17 immediately to the care of a paediatric specialist. Treatment should be
18 with parenteral antibiotics in line with the NICE guideline on fever in under
19 5s.

20 1.2.1.3 For infants and children 3 months or older with acute pyelonephritis/upper
21 urinary tract infection:

22  consider referral to a paediatric specialist

23  treat with oral antibiotics for 7–10 days. The use of an oral antibiotic
24 with low resistance patterns is recommended, for example
25 cephalosporin or co-amoxiclav
26  if oral antibiotics cannot be used, treat with an intravenous (IV)
27 antibiotic agent such as cefotaxime or ceftriaxone for 2–4 days followed
28 by oral antibiotics for a total duration of 10 days. [2007]

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1 1.2.1.4 For infants and children 3 months or older with cystitis/lower urinary tract
2 infection:

3  Treat with oral antibiotics for 3 days. The choice of antibiotics should be
4 directed by locally developed multidisciplinary guidance. Trimethoprim,
5 nitrofurantoin, cephalosporin or amoxicillin may be suitable.
6  The parents or carers should be advised to bring the infant or child for
7 reassessment if the infant or child is still unwell after 24–48 hours. If an
8 alternative diagnosis is not made, a urine sample should be sent for
9 culture to identify the presence of bacteria and determine antibiotic
10 sensitivity if urine culture has not already been carried out. [2007]

11 1.2.1.5 For infants and children who receive aminoglycosides (gentamicin or

12 amikacin), once daily dosing is recommended. [2007]

13 1.2.1.6 If parenteral treatment is required and IV treatment is not possible,

14 intramuscular treatment should be considered. [2007]

15 1.2.1.7 If an infant or child is receiving prophylactic medication and develops an

16 infection, treatment should be with a different antibiotic, not a higher dose
17 of the same antibiotic. [2007]

18 1.2.1.8 Asymptomatic bacteriuria in infants and children should not be treated

19 with antibiotics. [2007]

20 1.2.1.9 Laboratories should monitor resistance patterns of urinary pathogens and

21 make this information routinely available to prescribers. [2007]

22 1.2.2 Prevention of recurrence

23 1.2.2.1 Dysfunctional elimination syndromes and constipation should be

24 addressed in infants and children who have had a UTI. [2007]

25 1.2.2.2 Children who have had a UTI should be encouraged to drink an adequate
26 amount. [2007]

27 1.2.2.3 Children who have had a UTI should have ready access to clean toilets
28 when required and should not be expected to delay voiding. [2007]

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1 1.2.3 Antibiotic prophylaxis

2 1.2.3.1 Antibiotic prophylaxis should not be routinely recommended in infants and

3 children following first-time UTI. [2007]

4 1.2.3.2 Antibiotic prophylaxis may be considered in infants and children with

5 recurrent UTI. [2007]

6 1.2.3.3 Asymptomatic bacteriuria in infants and children should not be treated

7 with prophylactic antibiotics. [2007]

8 1.3 Imaging tests

9 1.3.1.1 Infants and children with atypical UTI (see box 1) should have ultrasound
10 of the urinary tract during the acute infection to identify structural
11 abnormalities of the urinary tract such as obstruction, as outlined in
12 tables 4, 5 and 6. This is to ensure prompt management. [2007]

13 1.3.1.2 For infants younger than 6 months with first-time UTI that responds to
14 treatment, ultrasound should be carried out within 6 weeks of the UTI, as
15 outlined in table 4. [2007]

16 1.3.1.3 For infants and children aged 6 months and older with first-time UTI that
17 responds to treatment, routine ultrasound is not recommended unless the
18 infant or child has atypical UTI, as outlined in tables 5 and 6. [2007]

19 1.3.1.4 Infants and children who have had a lower urinary tract infection should
20 undergo ultrasound (within 6 weeks) only if they are younger than
21 6 months or have had recurrent infections. [2007]

22 1.3.1.5 A DMSA scan 4–6 months following the acute infection should be used to
23 detect renal parenchymal defects, as outlined in tables 4, 5 and 6. [2007]

24 1.3.1.6 If the infant or child has a subsequent UTI while awaiting DMSA, the
25 timing of the DMSA should be reviewed and consideration given to doing
26 it sooner. [2007]

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1 1.3.1.7 Routine imaging to identify VUR is not recommended for infants and
2 children who have had a UTI, except in specific circumstances, as
3 outlined in tables 4, 5 and 6. [2007]

4 1.3.1.8 When a micturating cystourethrogram (MCUG) is performed, prophylactic

5 antibiotics should be given orally for 3 days with MCUG taking place on
6 the second day. [2007]

7 1.3.1.9 Infants and children who have had a UTI should be imaged as outlined in
8 tables 4, 5 and 6. [2007]

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1 Table 4 Recommended imaging schedule for infants younger than 6 months

Test Responds well to Atypical UTIa Recurrent
treatment within UTIa
48 hours
Ultrasound during No Yesc Yes
the acute infection
Ultrasound within Yesb No No
6 weeks
DMSA 4–6 months No Yes Yes
following the acute
infection
MCUG No Yes Yes
a
See box 1 for definition
b
If abnormal consider MCUG
c
In an infant or child with a non-E. coli-UTI, responding well to antibiotics and with no
other features of atypical infection, the ultrasound can be requested on a non-urgent
basis to take place within 6 weeks

2 Table 5 Recommended imaging schedule for infants and children 6 months or

3 older but younger than 3 years
Test Responds well to Atypical UTIa Recurrent
treatment within UTIa
48 hours
Ultrasound during the No Yesc No
acute infection
Ultrasound within No No Yes
6 weeks
DMSA 4–6 months No Yes Yes
following the acute
infection
MCUG No Nob Nob
a
See box 1 for definition
b
While MCUG should not be performed routinely it should be considered if the following
features are present:
 dilatation on ultrasound
 poor urine flow
 non-E. coli-infection
 family history of VUR.
c
In an infant or child with a non-E. coli-UTI, responding well to antibiotics and with no
other features of atypical infection, the ultrasound can be requested on a non-urgent basis
to take place within 6 weeks

4 Table 6 Recommended imaging schedule for children 3 years or older

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Test Responds well to Atypical UTIa Recurrent

treatment within UTIa
48 hours
Ultrasound during the No Yesb c No
acute infection
Ultrasound within No No Yesb
6 weeks
DMSA 4–6 months No No Yes
following the acute
infection
MCUG No No No
a
See box 1 for definition
b
Ultrasound in toilet-trained children should be performed with a full bladder with an
estimate of bladder volume before and after micturition.
c
In a child with a non-E. coli-UTI, responding well to antibiotics and with no other features
of atypical infection, the ultrasound can be requested on a non-urgent basis to take place
within 6 weeks
1

Box 1 Definitions of atypical and recurrent UTI

Atypical UTI includes:
seriously ill (for more information refer to the NICE guideline on fever in under
5s)
 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.
Recurrent UTI:
 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 episode of UTI with cystitis/lower urinary tract infection, or
 three or more episodes of UTI with cystitis/lower urinary tract infection.

2 1.4 Surgical intervention

3 1.4.1.1 Surgical management of VUR is not routinely recommended. [2007]

4 1.5 Follow-up
5 1.5.1.1 Infants and children who do not undergo imaging investigations should not
6 routinely be followed up. [2007]

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1 1.5.1.2 The way in which the results of imaging will be communicated should be
2 agreed with the parents or carers or the young person as appropriate.
3 [2007]

4 1.5.1.3 When results are normal, a follow-up outpatient appointment is not

5 routinely required. Parents or carers should be informed of the results of
6 all the investigations in writing. [2007]

7 1.5.1.4 Infants and children who have recurrent UTI or abnormal imaging results
8 should be assessed by a paediatric specialist. [2007]

9 1.5.1.5 Assessment of infants and children with renal parenchymal defects should
10 include height, weight, blood pressure and routine testing for proteinuria.
11 [2007]

12 1.5.1.6 Infants and children with a minor, unilateral renal parenchymal defect do
13 not need long-term follow-up unless they have recurrent UTI or family
14 history or lifestyle risk factors for hypertension. [2007]

15 1.5.1.7 Infants and children who have bilateral renal abnormalities, impaired
16 kidney function, raised blood pressure and/or proteinuria should receive
17 monitoring and appropriate management by a paediatric nephrologist to
18 slow the progression of chronic kidney disease. [2007]

19 1.5.1.8 Infants and children who are asymptomatic following an episode of UTI
20 should not routinely have their urine re-tested for infection. [2007]

21 1.5.1.9 Asymptomatic bacteriuria is not an indication for follow-up. [2007]

22 1.6 Information and advice for children, young people and

23 parents or carers
24 1.6.1.1 Healthcare professionals should ensure that when a child or young person
25 has been identified as having a suspected UTI, they and their parents or
26 carers as appropriate are given information about the need for treatment,
27 the importance of completing any course of treatment and advice about
28 prevention and possible long-term management. [2007]

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1 1.6.1.2 Healthcare professionals should ensure that children and young people,
2 and their parents or carers as appropriate, are aware of the possibility of a
3 UTI recurring and understand the need for vigilance and to seek prompt
4 treatment from a healthcare professional for any suspected reinfection.
5 [2007]

6 1.6.1.3 Healthcare professionals should offer children and young people and/or
7 their parents or carers appropriate advice and information on:

8  prompt recognition of symptoms

9  urine collection, storage and testing
10  appropriate treatment options
11  prevention
12  the nature of and reason for any urinary tract investigation
13  prognosis
14  reasons and arrangements for long-term management if required.
15 [2007]

16 Putting this guideline into practice

17 [This section will be finalised after consultation]

18 NICE has produced tools and resources [link to tools and resources tab] to help you
19 put this guideline into practice.

20 Putting recommendations into practice can take time. How long may vary from
21 guideline to guideline, and depends on how much change in practice or services is
22 needed. Implementing change is most effective when aligned with local priorities.

23 Changes recommended for clinical practice that can be done quickly – like changes
24 in prescribing practice – should be shared quickly. This is because healthcare
25 professionals should use guidelines to guide their work – as is required by
26 professional regulating bodies such as the General Medical and Nursing and
27 Midwifery Councils.

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1 Changes should be implemented as soon as possible, unless there is a good reason

2 for not doing so (for example, if it would be better value for money if a package of
3 recommendations were all implemented at once).

4 Different organisations may need different approaches to implementation, depending

5 on their size and function. Sometimes individual practitioners may be able to respond
6 to recommendations to improve their practice more quickly than large organisations.

7 Here are some pointers to help organisations put NICE guidelines into practice:

8 1. Raise awareness through routine communication channels, such as email or

9 newsletters, regular meetings, internal staff briefings and other communications with
10 all relevant partner organisations. Identify things staff can include in their own
11 practice straight away.

12 2. Identify a lead with an interest in the topic to champion the guideline and motivate
13 others to support its use and make service changes, and to find out any significant
14 issues locally.

15 3. Carry out a baseline assessment against the recommendations to find out

16 whether there are gaps in current service provision.

17 4. Think about what data you need to measure improvement and plan how you
18 will collect it. You may want to work with other health and social care organisations
19 and specialist groups to compare current practice with the recommendations. This
20 may also help identify local issues that will slow or prevent implementation.

21 5. Develop an action plan, with the steps needed to put the guideline into practice,
22 and make sure it is ready as soon as possible. Big, complex changes may take
23 longer to implement, but some may be quick and easy to do. An action plan will help
24 in both cases.

25 6. For very big changes include milestones and a business case, which will set out
26 additional costs, savings and possible areas for disinvestment. A small project group
27 could develop the action plan. The group might include the guideline champion, a
28 senior organisational sponsor, staff involved in the associated services, finance and
29 information professionals.

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1 7. Implement the action plan with oversight from the lead and the project group.
2 Big projects may also need project management support.

3 8. Review and monitor how well the guideline is being implemented through the
4 project group. Share progress with those involved in making improvements, as well
5 as relevant boards and local partners.

6 NICE provides a comprehensive programme of support and resources to maximise

7 uptake and use of evidence and guidance. See our into practice pages for more
8 information.

9 Also see Leng G, Moore V, Abraham S, editors (2014) Achieving high quality care –
10 practical experience from NICE. Chichester: Wiley.

11 Context
12 In the past 30–50 years, the natural history of urinary tract infection (UTI) in children
13 has changed as a result of the introduction of antibiotics and improvements in
14 healthcare. This change has contributed to uncertainty about the most appropriate
15 and effective way to manage UTI in children, and whether or not investigations and
16 follow-up are justified.

17 UTI is a common bacterial infection causing illness in infants and children. It may be
18 difficult to recognise UTI in children because the presenting symptoms and signs are
19 non-specific, particularly in infants and children younger than 3 years. Collecting
20 urine and interpreting results are not easy in this age group, so it may not always be
21 possible to unequivocally confirm the diagnosis.

22 Current management, which includes imaging, prophylaxis and prolonged follow-up,

23 has placed a heavy burden on NHS primary and secondary care resources. It is
24 costly, based on limited evidence and is unpleasant for children and distressing for
25 their parents or carers. The guideline has been developed with the aim of providing
26 guidance on several aspects of UTI in infants and children from birth up to the age of
27 16 years, including: when to consider the diagnosis of UTI in sick and/or
28 symptomatic infants and children who were previously healthy; urine collection for
29 the diagnosis of UTI in infants and children; tests to establish or exclude UTI;

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1 treatment, including symptomatic reinfection; use of prophylactic antibiotics and

2 investigations to assess the structure and function of the urinary tract; referral to
3 secondary and tertiary care; surgical intervention; long-term follow-up; and advice to
4 give to parents or carers, including what to do if another UTI occurs.

5 Areas not addressed by the guideline include children with urinary catheters in situ,
6 children with neurogenic bladders, children already known to have significant pre-
7 existing uropathies, children with underlying renal disease (for example, nephrotic
8 syndrome), immunosupressed children, and infants and children in intensive care
9 units. It also does not cover preventive measures or long-term management of
10 sexually active girls with recurrent UTI.

11 In 2017, we updated the recommendations on urine testing strategies for infants and
12 children under 3 years.

13 More information
To find out what NICE has said on topics related to this guideline, see our web
page on urological conditions.

14 Recommendations for research

15 In 2007, the guideline committee made the following recommendations for research.
16 The committee’s full set of research recommendations is detailed in the full
17 guideline.

18 1 Antibiotic prophylaxis
19 Well-designed randomised, double-blind, placebo-controlled trials are required to
20 determine the effectiveness of prophylactic antibiotics for preventing subsequent
21 symptomatic UTIs and renal parenchymal defects in children.

22 Why this is important

23 A high proportion of girls and a minority of boys with UTI develop further infections,
24 which may be acutely distressing, associated with systemic illness and possible
25 subsequent renal damage. Renal damage is most likely in children with high grade
26 vesicoureteric reflux (VUR) and this is the reason for some of the imaging tests

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1 previously recommended. Prophylactic antibiotics have been used on the

2 assumption that they prevent these problems. However, chronic antibiotic use has a
3 number of disadvantages for the individual as well as the population as a whole.
4 Formal evaluation of whether prophylactic antibiotics can prevent the distressing
5 symptoms and scarring associated with recurrent UTI would affect not only the use
6 of antibiotics, but also the imaging investigations recommended.

7 2 Surgical intervention
8 Well-designed randomised placebo-controlled trials are required to determine the
9 effectiveness of prophylaxis or various surgical procedures for the management of
10 VUR in preventing recurrent UTI or renal parenchymal defects.

11 Why this is important

12 Management strategies for children with recurrent UTI have been based on the
13 assumption that prevention of UTI and/or renal parenchymal defects by surgery or
14 prophylaxis is more effective in preventing renal damage than treating symptomatic
15 infections promptly whenever they occur. In addition, there have been recent
16 developments in minimally invasive surgery which have been shown to be relatively
17 safe and effective in reducing or eliminating VUR. Studies comparing these
18 interventions with adequate controls are recommended to establish the benefit of
19 surgery in preventing recurrent symptomatic infection and renal damage.

20 3 Long-term risk
21 A well designed cohort study investigating long-term outcomes including renal
22 scarring and renal function of children who have had UTI should be conducted in the
23 UK.

24 Why this is important

25 UTI and VUR in young children have been shown to be associated with both
26 congenital and acquired renal damage. Progressive scarring is well documented in
27 children with high grade VUR and recurrent UTI. Scarring has been associated with
28 severe hypertension, proteinuria, complications in pregnancy and progression to
29 established renal failure. These risks are likely to be greater in children with bilateral
30 renal parenchymal defects. However, the frequency and magnitude of these risks for

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1 children with unilateral and bilateral renal damage are unclear. Knowledge of the risk
2 of serious or progressive complications would be useful to determine the
3 management of children with first-time and recurrent UTIs.

4 Update information
5 New recommendation have been added for the urine testing strategies for infants
6 and children under 3 years.

7 These are marked as:

8  [2017]

9 NICE proposes to delete some recommendations from the 2007 guideline, because
10 either the evidence has been reviewed and the recommendations have been
11 updated, or NICE has updated other relevant guidance and has replaced the original
12 recommendations. Recommendations that have been deleted or changed sets out
13 these recommendations and includes details of replacement recommendations.
14 Where there is no replacement recommendation, an explanation for the proposed
15 deletion is given.

16 Where recommendations are shaded in grey and end [2007], the evidence has not
17 been reviewed since the original guideline.

18 See also the original NICE guideline and supporting documents.

19 Recommendations that have been deleted or changed

20 Recommendations to be deleted
21

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Recommendation in 2007 guideline Comment

All infants younger than 3 months with 1.1.5.2 Refer all infants under 3 months
suspected UTI (see table 1) should be with a suspected UTI (see table 1) to
referred to paediatric specialist care and paediatric specialist care, and
a urine sample should be sent for urgent • send a urine sample for urgent
microscopy and culture. These infants microscopy and culture
should be managed in accordance with
• manage in line with the NICE
the recommendations for this age group
guideline on fever in under 5s.
in the NICE guideline on fever in under
5s.

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Replaced by:
Urgent microscopy and culture is the 1.1.5.3 Use dipstick testing for infants
preferred method for diagnosing UTI and children 3 months or older but
in this age group; this should be used younger than 3 years with suspected
where possible. UTI.
If the infant Urgent microscopy and • If both leukocyte esterase and
or child has culture should be nitrite are negative: do not start antibiotic
specific arranged and antibiotic treatment; do not send a urine sample for
urinary treatment should be microscopy and culture unless at least 1
symptoms started. of the criteria in recommendation 1.1.6.1
When urgent apply.
microscopy is not • If leukocyte esterase or nitrite, or
available, a urine both are positive: start antibiotic
sample should be sent treatment; send a urine sample for
for microscopy and microscopy and culture.
culture, and antibiotic
treatment should be
started.
If the For an infant or child
symptoms with a high risk of
are non- serious illness: the
specific to infant or child should
UTI be urgently referred to
a paediatric specialist
where a urine sample
should be sent for
urgent microscopy and
culture. Such infants
and children should be
managed in line with
the NICE guideline on
fever in under 5s.
For an infant or child
with an intermediate
risk of serious illness: if
the situation demands,
the infant or child may
be referred urgently to
a paediatric specialist.
For infants and
children who do not
require paediatric
specialist referral,
urgent microscopy and
culture should be
arranged. Antibiotic
treatment should be
started if microscopy is
positive (see table 5).
When urgent
microscopy is not
available, dipstick
testing may act as a

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substitute. The
presence of nitrites
suggests the possibility
of infection and
antibiotic treatment
should be started (see
table 4). In all cases, a
urine sample should be
sent for microscopy
and culture.
For an infant or child
with a low risk of
serious illness:
microscopy and culture
should be arranged.
Antibiotic treatment
should only be started
if microscopy or culture
is positive.
1.1.6.1 Urine samples should be sent for Replaced by:
culture: 1.1.6.1 Urine samples should be sent for
• in infants and children who have a culture:
diagnosis of acute pyelonephritis/upper
• in infants and children who are
urinary tract infection (see 1.1.8.1)
considered to have acute
• in infants and children with a high
pyelonephritis/upper urinary tract
to intermediate risk of serious illness
infection (see 1.1.8.1)
• in infants and children under 3
years • in infants and children with a high
• in infants and children with a to intermediate risk of serious illness
single positive result for leukocyte • in infants under 3 months
esterase or nitrite • in infants and children with a
• in infants and children with positive result for leukocyte esterase or
recurrent UTI nitrite
• in infants and children with an • in infants and children with
infection that does not respond to recurrent UTI
treatment within 24–48 hours, if no
sample has already been sent • in infants and children with an
• when clinical symptoms and infection that does not respond to
dipstick tests do not correlate. treatment within 24–48 hours, if no
sample has already been sent
• when clinical symptoms and
dipstick tests do not correlate.
1

2 ISBN:

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