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Urinary tract infection in under 16s: diagnosis and management
NICE guideline [NG224]Published: 27 July 2022
This guideline covers diagnosing and managing first or recurrent upper or lower urinary tract infection (UTI) in babies, children and young people under 16. It aims to achieve more consistent clinical practice, based on accurate diagnosis and effective 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.
Consider testing the urine of babies, children and young people if they are unwell and there is a suspicion of a UTI present.
Refer babies under 3 months with a suspected UTI to paediatric specialist care and send a urine sample for urgent microscopy and culture.
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.
Symptoms and signs that increase the likelihood that a urinary tract infection (UTI) is present | Symptoms and signs that decrease the likelihood that a UTI is present |
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When using the table, be aware that:
The symptoms and signs in this table should be used to inform a decision about whether urine collection and testing is necessary.
It is not an exhaustive list of symptoms or signs and should be used as a guide alongside clinical judgement.
The presence or absence of a single symptom or sign in isolation in either column should not necessarily be used to decide whether or not to test for UTI.
Multiple symptoms and signs will probably increase the likelihood that there is a UTI.
It may be useful to consider alternative diagnoses where the symptoms and signs decrease the likelihood that a UTI is present.
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.
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.
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.
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).
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.
Use a clean catch method for urine collection wherever possible.
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.
Do not use cotton wool balls, gauze or sanitary towels to collect urine from babies and children.
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.
Immediately refrigerate or use boric acid to preserve urine samples that are to be cultured but cannot be cultured within 4 hours of collection.
Use dipstick testing for babies and children between 3 months and 3 years with suspected UTI, and:
Urine dipstick test result | Strategy |
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Leukocyte esterase and nitrite are both positive | Assume the child has a urinary tract infection (UTI) and give them antibiotics. If the child has a high or intermediate risk of serious illness or a history of previous UTI, send a urine sample for culture. |
Leukocyte esterase is negative and nitrite is positive | Give the child antibiotics if the urine test was carried out on a fresh urine sample. Send a urine sample for culture. Subsequent management will depend on the result of urine culture. |
Leukocyte esterase is positive and nitrite is negative | Send a urine sample for microscopy and culture. Do not give the child antibiotics unless there is good clinical evidence of a UTI (for example, obvious urinary symptoms). A positive leukocyte esterase result may indicate an infection outside the urinary tract that may need to be managed differently. |
Leukocyte esterase and nitrite are both negative | Assume the child does not have a UTI. Do not give the child antibiotics for a UTI or send a urine sample for culture. Explore other possible causes of the child’s illness. |
Dipstick testing for leukocyte esterase and nitrite is diagnostically as useful as microscopy and culture, and can safely be used.
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.
Microscopy results | Interpretation |
|---|---|
Pyuria and bacteriuria are both positive | Assume the baby or child has a urinary tract infection (UTI) |
Pyuria is positive and bacteriuria is negative | Start antibiotic treatment if the baby or child has symptoms or signs of a UTI |
Pyuria is negative and bacteriuria is positive | Assume the baby or child has a UTI |
Pyuria and bacteriuria are both negative | Assume the baby or child does not have a UTI |
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.
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]
Do not use C-reactive protein alone to differentiate acute upper UTI from lower UTI in babies and children.
Immediately refer babies and children with a high risk of serious illness (see the section on assessment of risk of serious illness) to a paediatric specialist.
Immediately refer babies under 3 months with a suspected UTI to a paediatric specialist.
Paediatric specialists should give babies under 3 months with a suspected UTI parenteral antibiotics in line with the section on management by the paediatric specialist in the NICE guideline on fever in under 5s.
Consider referring babies and children over 3 months with upper UTI to a paediatric specialist.
Give babies and children over 3 months with an acute upper UTI antibiotics in line with the NICE guideline on pyelonephritis (acute): antimicrobial prescribing.
Give babies and children over 3 months with lower UTI antibiotics in line with the NICE guideline on urinary tract infection (lower): antimicrobial prescribing.
For information about treating babies and children who were already on prophylactic antibiotics who then developed a UTI see the NICE guidelines on pyelonephritis (acute): antimicrobial prescribing, urinary tract infection (lower): antimicrobial prescribing and urinary tract infection (recurrent): antimicrobial prescribing.
Do not use antibiotics to treat asymptomatic bacteriuria in babies and children.
Laboratories should monitor patterns of urinary pathogen resistance and make this information routinely available to prescribers.
Manage dysfunctional elimination syndromes and constipation in babies and children who have had a UTI.
Encourage children who have had a UTI to drink enough water to avoid dehydration.
Ensure that children who have had a UTI have access to clean toilets when needed and do not have to delay voiding unnecessarily.
Do not routinely give prophylactic antibiotics to babies and children following first-time UTI.
See the NICE guideline on urinary tract infection (recurrent): antimicrobial prescribing for prophylactic antibiotic treatment for recurrent UTI in babies and children.
Do not give prophylactic antibiotics to babies and children with asymptomatic bacteriuria.
Send babies and children with atypical UTI (see box 1) for a urinary tract ultrasound during the acute infection, to identify structural abnormalities such as obstruction and to ensure prompt management.
Send babies younger than 6 months with first-time UTI that responds to treatment for ultrasound within 6 weeks of the UTI.
Do not routinely send babies and children over 6 months with first-time UTI who respond to treatment for an ultrasound, unless they have atypical UTI.
Babies and children who have had a lower UTI should be sent for ultrasound (within 6 weeks) only if they:
are younger than 6 months or
have had recurrent infections.
Use a DMSA scan 4 to 6 months after the acute infection to detect renal parenchymal defects in babies and children.
If the baby or child has a subsequent UTI while waiting for a DMSA scan, review the timing of the scan and consider doing it sooner.
Do not routinely use imaging to identify VUR in babies and children who have had a UTI, except in specific circumstances.
When a micturating cystourethrogram (MCUG) is done, give prophylactic antibiotics orally for 3 days with the MCUG on the second day.
Atypical UTI includes:
Seriously ill (for more information, refer to the NICE guideline on fever in under 5s: assessment and initial management)
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 upper UTI (acute pyelonephritis), or
One episode of UTI with acute upper UTI plus 1 or more episodes of UTI with lower UTI (cystitis), or
Three or more episodes of UTI with lower UTI