This document provides clinical guidance for all staff involved in the care and management of a child presenting to an Emergency Department (ED) with symptoms suggestive of a urinary tract infection (UTI) in Queensland.
This guideline has been developed by senior ED clinicians and Paediatricians across Queensland, with input from Infectious diseases, Pharmacy and Nephrology, Queensland Children’s Hospital, Brisbane. It has been endorsed for use state-wide by the Queensland Emergency Care of Children Working Group in partnership with the Queensland Emergency Department Strategic Advisory Panel and the Healthcare Improvement Unit, Clinical Excellence Queensland.
UTIs are common in childhood. An estimated 2% of boys and 8% of girls will experience a UTI by seven years of age. UTIs are the most common SBI in children aged less than 5 years.1-3
| Age | Frequency |
|---|---|
| Less than 1 year | 6.5% girls, 1.2% circumcised boys, 8% uncircumcised boys |
| 1 – 2 years | 8.1% girls, 1.9% boys |
| Greater than 2 years | Decreased frequency thereafter |
Non-specific clinical presentation and difficulties in obtaining urinary specimens in infants and young children can make the diagnosis of UTI challenging.1-6
Consider a sepsis diagnosis in child presenting with toxic features including tachypnoea, increased work of breathing, grunt, weak cry, marked/persistent tachycardia, moderate to severe dehydration. Refer to the sepsis pathway.
Refer to the Febrile illness guideline for the assessment of children with a fever ≥38⁰ C without localising signs. In general, the younger the infant or child, the lower the threshold for urine screening.3-6
The clinical features on history are variable and age-dependant.
| Age less than 3 months | Age between 3 months and 3 years | Age 3 years and older |
|---|---|---|
|
Fever Vomiting Lethargy Irritability Poor feeding Failure to thrive Abdominal pain Jaundice Haematuria Offensive urine |
Fever Abdominal pain Loin tenderness Vomiting Poor feeding Lethargy Irritability Haematuria Offensive urine Failure to thrive |
Urinary frequency Dysuria Dysfunctional voiding Changes to continence Abdominal pain Loin tenderness Fever Malaise Vomiting Haematuria Offensive urine Cloudy urine |
History should also include specific information on:
Physical examination should include a thorough abdominal examination (to identify masses or suggestion of pyelonephritis), examination of external genitalia (to identify genitourinary abnormalities which predispose to UTI), lower limb neurological examination (impaired bladder emptying due to neurological aetiology) and hydration status. Blood pressure should be measured.
No physical sign is pathognomonic for a UTI.7,8 Other than fever, signs may include hypertension, a palpable bladder, dribbling or straining, and loin or suprapubic tenderness. Distinguishing clinically between lower (cystitis) and upper (pyelonephritis) UTI can be challenging. Pyelonephritis is more likely in younger infants, and more likely to have systemic features such as fever (with rigors), vomiting, malaise and loin tenderness.
Suspect upper renal tract involvement for a child with any of the following:
All children who present with urinary symptoms should undergo urine testing.
In addition, all neonates who present with a fever ≥38⁰ C should have urine sent for microscopy to screen for UTI.3,6,9 A step-by-step approach can be taken for children aged between 29 days to 3 months, with a low threshold to consider UTI as a diagnosis.3,6 Urine testing can be safely deferred in children with an unexplained fever who are ≥3 months of age and otherwise well.4 For these children urine testing is only recommended if fever persists for more than 48 hours.5 Refer to the Febrile illness guideline for the additional investigations recommended in children with an unexplained fever.
Urine testing is not recommended on first presentation for children aged ≥3 months who have a clear alternative site of infection, and if verbal, no urinary symptoms.5 Consider testing for those who remain unwell on subsequent review.
The most appropriate urine collection method varies depending on age and clinical presentation.2,4,6
Selecting the most appropriate method of urine collection is crucial.
| Collection method | Utility | Notes |
|---|---|---|
| Supra-pubic bladder aspiration (SPA) |
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| Urethral catheterisation (CSU) “in-out catheter” |
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| Clean catch specimen (CCU) |
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| Midstream urine (MSU) |
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| Bag specimens |
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Well appearing children over 12 months of age with an unexplained fever can be discharged with a urine jar to collect a specimen for urine microscopy via their GP if assessment has otherwise been completed.
In catheterised children, collect a specimen and contact the treating team. Catheters should only be exchanged on specialist advice.
| Leucocytes | Nitrites | Send for M/C/S | Likelihood of UTI |
|---|---|---|---|
| Positive | Positive | Y | Likely |
| Negative | Positive | Y | Possible |
| Positive | Negative | Y | Possible |
| Negative | Negative | Only if age <3 months | Unlikely (unless aged <3 months) |
Considerations:
| |||
Urine microscopy can be used as an additional screening tool to dipstick testing. The presence of bacteria and leucocytes on microscopy in a sample with less than 10 epithelial cells per high powered field are suggestive of UTI.8
A presumptive diagnosis of UTI can be made if:
Definitive diagnosis of a UTI requires growth of a single organism on urine culture.
Mixed growth may indicate a contaminated specimen.
Investigations including USS and bloods are not routinely recommended.
Consider imaging (initially ultrasound) for the following children:
Consider sexually transmitted infection (STI) screening including gonorrhoea and chlamydia PCR testing on first pass urine where appropriate.
Refer to flowchart [PDF 300.46 KB] for a summary of the emergency management of children presenting with a urinary tract infection.
Seek urgent paediatric critical care advice (onsite or via Retrieval Services Queensland (RSQ)) for a child with life-threatening sepsis.
Seek senior emergency/paediatric advice if sepsis is suspected.
Children with apparent sepsis or in shock should be treated with parenteral antibiotics and intravenous fluids – refer to CHQ Antibiocard and the Queensland Paediatric Sepsis Pathway. Refer to the Sepsis guideline for recommended investigations.
Do not delay antibiotic administration for urine collection in child with suspected sepsis.
Consider a lumbar puncture in neonates (age less than 29 days) with a UTI given the relatively higher incidence of co-existing meningitis.15-16
Seek senior emergency/paediatric advice as per local practice for the following children:
Empiric antibiotic therapy is recommended following a presumptive UTI diagnosis on dipstick testing or initial urine microscopy while the sample is being cultured and tested for sensitivities.
Treatment is age-dependent and should be tailored to clinical severity. Broad spectrum oral antibiotics will treat most uncomplicated UTIs. In the non-vomiting child, oral antibiotics are as effective as parenteral antibiotics due to high urinary concentrations.17-18
Antibiotics IV are recommended for children who are unable to tolerate oral antibiotics. Some hospitals may have a HITH (hospital in the home) program to facilitate this.
Clinicians working in Townsville [PDF] (access via QH intranet), Cairns (access via QH intranet) and Gold Coast University Hospital and Health Services should follow their local paediatric empirical antimicrobial therapy guidelines. Clinicians elsewhere in Queensland should follow the Children’s Health Queensland paediatric antimicrobial prescribing guidelines until the results of microbiological investigations are available.
Administer empiric antibiotic therapy following a presumptive UTI diagnosis on initial urine microscopy while the sample is being cultured and tested for sensitivities.
Antibiotics IV are recommended for all infants less than three months of age due to the higher risk of bacteraemia, sepsis and mortality.
Co-existing meningitis can occur especially in neonates.15-16 Seek senior advice regarding lumbar puncture for an infant with a presumptive UTI diagnosis.
Patients with a presumptive UTI diagnosis and loin/flank pain, renal angle tenderness or abdominal pain, should be investigated for pyelonephritis or a perinephric abscess. Recommended investigations include a FBC, renal function, blood culture and an ultrasound of the renal tract to identify a perinephric collection.
Prophylactic antibiotics are typically changed to an empiric antibiotic until definitive cultures and sensitivities are obtained. Discuss with the child’s General Paediatrician.
Pyuria should not be used as the sole criteria for the diagnosis of UTI in catheterised children. Bacterial colonisation of long-term catheters is common, and these children are often asymptomatic despite pyuria and bacteriuria.4
Empiric and/or prophylactic antibiotics should be decided on a case by case basis, ideally after discussion with the child’s General Paediatrician and where relevant, Infectious Disease physician and Surgical team. Improper use of antibiotics in this cohort may encourage the development of antibiotic resistance.
Empiric antibiotics in children with renal tract anomalies (including congenital genitourinary tract malformations, dysfunctional or surgically altered urinary tract) should be decided on a case by case basis, ideally after discussion with their General Paediatrician and where relevant Infectious Disease physician and Surgical team. Improper use of antibiotics in this cohort may encourage the development of antibiotic resistance.
Sexually transmitted infections (STIs) can have a similar clinical presentation to UTIs.19 Untreated STIs may lead to poor fertility and pelvic inflammatory disease. Consider gonorrhoea and chlamydia PCR testing on first pass urine in older symptomatic children. Children diagnosed with a gonorrhoea or chlamydia infection may require testing for other sexually transmitted disease (i.e. HIV, Hepatitis B or C).
Clinicians can contact the services below if escalation of care outside of senior clinicians within the ED is needed, as per local practices. Most children will be managed as an outpatient.
| Includes children with the following (as a guide) | |||
|---|---|---|---|
| |||
| Less than 2 weeks | Less than 1 year | 1-8 years | Over 12 Years |
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| Reason for contact | Who to contact |
|---|---|
| For immediate onsite assistance including airway management | The most senior resources available onsite at the time as per local practices. Options may include:
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| Paediatric critical care advice and endocrine advice and assistance | Onsite or via Retrieval Services Queensland (RSQ). If no onsite paediatric critical care service contact RSQ on 1300 799 127:
RSQ (access via QH intranet) Notify early of child potentially requiring transfer. Consider early involvement of local paediatric/critical care service. In the event of retrieval, inform your local paediatric service. |
| May include children with |
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| Reason for contact | Who to contact |
|---|---|
| Advice (including management, disposition or follow-up of children with no known comorbidities) |
Follow local practices. Options:
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| Advice (re empiric antibiotic therapy for child with long-term catheter, on prophylactic antibiotics or with renal tract anomalies) | The first point of call should be the child’s General Paediatrician. Additional advice may be sought from onsite/local ID specialist |
| Referral | First point of call is the onsite/local specialist or paediatric service |
| Do I need a critical transfer? |
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| Request a non-critical inter-hospital transfer |
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| Non-critical transfer forms |
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Discharge with GP follow-up of culture and sensitivity results may be considered for relatively well children aged three months or older.
Seek senior emergency/paediatric advice prior to considering discharge for all children with fever aged between 29 days and 3 months regardless of urine microscopy results.
On discharge educate carers on measures to minimise the risk of future UTIs including:
Admission is recommended for the following children:
Consider admission and further investigation (including renal ultrasound) for the following children: