Urinary tract infection in under 16s: diagnosis and management

Test the urine of babies, children and young people who have symptoms and signs that increase the likelihood that a urinary tract infection (UTI) is present (see table 1 and the explanation of how to use the table beneath it). [2022]

Consider testing the urine of babies, children and young people if they are unwell and there is a suspicion of a UTI but none of the signs or symptoms listed in table 1 are present. [2022]

Refer babies under 3 months with a suspected UTI (see table 1 and recommendation 1.1.2) to paediatric specialist care, and:

• send a urine sample for urgent microscopy and culture

• manage in line with the sections on management by the non-paediatric practitioner and management by the paediatric specialist in the NICE guideline on fever in under 5s: assessment and initial management. [2017, amended 2022]

Do not routinely test the urine of babies, children and young people 3 months and over who have symptoms and signs that suggest an infection other than a UTI. If they remain unwell and there is diagnostic uncertainty, consider urine testing. [2022]

For babies or children under 5 with fever with no obvious cause where a UTI is no longer suspected, see the NICE guideline on fever in under 5s: assessment and initial management. [2022]

Paediatric specialists should consult the section on management by the paediatric specialist in the NICE guideline on fever in under 5s: assessment and initial management, which covers when to test urine for a UTI in babies and children under 5 with fever who are in their care. [2022]

Avoid delay when collecting and testing the urine sample. If the sample cannot be collected at the consultation, advise the parents or carers (as appropriate) to collect and return the urine sample as soon as possible, ideally within 24 hours. [2022]

See the sections on urine collection, preservation and testing.

If a baby, child or young person has suspected sepsis, assess and manage their condition in line with the NICE guideline on sepsis: recognition, diagnosis and early management. [2022]

If a baby of up to and including 28 days corrected gestational age has suspected or confirmed bacterial infection, assess and manage their condition in line with the NICE guideline on neonatal infection: antibiotics for prevention and treatment. For early-onset neonatal infection, see the section on assessing and managing the risk of early-onset neonatal infection after birth, and for late-onset neonatal infection, see the section on risk factors for and clinical indicators of possible late-onset neonatal infection in the NICE guideline on neonatal infection: antibiotics for prevention and treatment. [2022]

For guidance on when to consider sexual abuse, see recommendation 1.1.21 in the NICE guideline on child maltreatment.

Assess the level of illness in babies and children in accordance with the section on clinical assessment of children with fever in the NICE guideline on fever in under 5s: assessment and initial management. [2007]

Take urine samples from children and young people before they are given antibiotics. This is in line with the NICE antimicrobial prescribing guidelines on pyelonephritis (acute) and urinary tract infection (lower). [2022]

Babies and children with a high risk of serious illness should have a urine sample taken, but treatment should not be delayed if a urine sample cannot be obtained. [2007]

Use a clean catch method for urine collection wherever possible. [2007]

If a clean catch urine sample is not possible, use other non-invasive methods such as urine collection pads. It is important to follow the manufacturer's instructions when using urine collection pads. [2007]

Do not use cotton wool balls, gauze or sanitary towels to collect urine from babies and children. [2007]

Use catheter samples or suprapubic aspiration (SPA) when it is not possible or practical to collect urine by non-invasive methods. Use ultrasound guidance to confirm that there is urine in the bladder before SPA. [2007]

Immediately refrigerate or use boric acid to preserve urine samples that are to be cultured but cannot be cultured within 4 hours of collection. [2007]

Follow the manufacturer's instructions when using boric acid to ensure the correct specimen volume and avoid potential toxicity against bacteria in the specimen. [2007]

Use dipstick testing for babies and children between 3 months and 3 years with suspected UTI, and:

• if both leukocyte esterase and nitrite are negative:

  • do not give antibiotics

  • do not send a urine sample for microscopy and culture unless at least 1 of the criteria in recommendation 1.1.21 apply.

• if leukocyte esterase or nitrite, or both are positive:

  • send the urine sample for culture

  • give antibiotics. [2017]

Use the urine-testing strategy for children aged 3 years or older shown in table 2. Assess the risk of serious illness in line with the section on clinical assessment of children with fever in 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. [2007]

Send urine samples for culture if a baby or child:

• is thought to have acute upper UTI (pyelonephritis; see the section on clinical differentiation between acute upper UTI and lower UTI)

• has a high to intermediate risk of serious illness (see the section on assessment of risk of serious illness)

• is under 3 months old

• has a positive result for leukocyte esterase or nitrite

• has recurrent UTI

• has an infection that does not respond to treatment within 24 to 48 hours, if no sample has already been sent

• has clinical symptoms and signs but dipstick tests do not correlate. [2017]

Interpret microscopy results as shown in table 3. [2007]

Use clinical criteria for decision making if a urine test does not support findings, because in a small number of cases, this may be the result of a false negative. [2007]

Record the following risk factors for UTI and serious underlying pathology:

• poor urine flow

• history suggesting previous UTI or confirmed previous UTI

• recurrent fever of uncertain origin

• antenatally diagnosed renal abnormality

• family history of vesicoureteral reflux (VUR) or renal disease

• constipation

• dysfunctional voiding

• enlarged bladder

• abdominal mass

• evidence of spinal lesion

• poor growth

• high blood pressure. [2007]

Assume a diagnosis of acute upper UTI in babies or children who have either:

• bacteriuria and fever of 38°C or higher or

• bacteriuria, fever lower than 38°C and loin pain or tenderness. [2007]

Assume that babies and children who have bacteriuria but no systemic symptoms or signs have lower UTI (cystitis). [2007]

Do not use C-reactive protein alone to differentiate acute upper UTI from lower UTI in babies and children. [2007]

Manage dysfunctional elimination syndromes and constipation in babies and children who have had a UTI. [2007]

Encourage children who have had a UTI to drink enough water to avoid dehydration. [2007]

Ensure that children who have had a UTI have access to clean toilets when needed and do not have to delay voiding unnecessarily. [2007]

Do not routinely give prophylactic antibiotics to babies and children following first-time UTI. [2007]

See the NICE guideline on urinary tract infection (recurrent): antimicrobial prescribing for prophylactic antibiotic treatment for recurrent UTI in babies and children. [2018]

Do not give prophylactic antibiotics to babies and children with asymptomatic bacteriuria. [2007]

Do not routinely use imaging to localise UTI. [2007]

In rare instances when it is clinically important to confirm or exclude acute upper UTI, use either:

• power doppler ultrasound or

• a dimercaptosuccinic acid (DMSA) scintigraphy scan if power doppler ultrasound is not available or the diagnosis has not been confirmed. [2007]