VOL: 103, ISSUE: 36, PAGE NO: 21
NICE (2007a) has recently published guidance, developed by the National Collaborating Centre for Women’s and Childr…
NICE (2007a) has recently published guidance, developed by the National Collaborating Centre for Women’s and Children’s Health, on the diagnosis and management of urinary tract infection (UTI) in children under 16 (NT News, 28 August, p7). According to NICE, UTIs affect an estimated 82,000 children each year. The guideline highlights recommendations in the following areas as key priorities for implementation: symptoms and signs; urine collection; urine testing; history and examination on confirmed UTI; acute management; antibiotic prophylaxis; and imaging tests. The guidance does not cover some specific groups of children, including those with urinary catheters in situ and those already known to have significant pre-existing uropathies.
The guidance states that the natural history of UTI in children has changed as a result of the introduction of antibiotics and improvements in healthcare. This change has contributed to uncertainty about the most effective way to manage UTI in children. The guidance adds that UTIs are common in children but acknowledges that they may be difficult to recognise due to non-specific presenting symptoms and signs, and that collecting urine and interpreting results are not easy in this age group. The aim of the guidance is to ‘achieve more consistent clinical practice, based on accurate diagnosis and effective management’ (NICE, 2007a).
The guidance stresses the importance of child-centred care, good communication with children and parents/carers, involving parents/carers in treatment decisions and the need for them to give consent to children’s care. It also makes a range of recommendations on information and advice for patients and parents (see Box, p22).
Symptoms and signs
The NICE guidance features a table that outlines the most common and least common symptoms and signs in babies under three months and in infants and children three months or older with UTI. It states that signs of a possible UTI include general symptoms such as fever, vomiting, tiredness and irritability. Specific signs include dysuria, frequency, wetting, abdominal pain and offensive urine.
The guidance suggests:
- Infants and children presenting with unexplained fever of 38 degsC or higher should have a urine sample tested within 24 hours;
- Infants and children with an alternative site of infection should not have a urine sample tested. When this group of remains unwell, urine testing should be considered after 24 hours at the latest;
- Babies and children with symptoms and signs suggestive of UTI should have a urine sample tested for infection.
To assess the risk of serious illness, babies’ and children’s illness level should be examined in line with NICE guidance on feverish illness in children (NICE, 2007b).
Urine collection and testing
A clean-catch sample is recommended for urine collection, but if this is not possible the guidance recommends:
- Other non-invasive methods such as urine collection pads should be used, following the manufacturer’s instructions when using them. Cotton-wool balls, gauze and sanitary towels should not be used to collect urine in infants and children;
- When it is not possible to collect urine by non-invasive methods, catheter samples or suprapubic aspiration (SPA) should be used;
- Before SPA is attempted, ultrasound guidance should be used to demonstrate the presence of urine in the bladder.
NICE emphasises that in an infant or child with a high risk of serious illness, it is ‘highly preferable’ that a urine sample is obtained, but treatment should not be delayed if this is unobtainable.
The guidance also outlines urine-testing strategies for: infants under three months; infants and children three months or older but under three years; and children three years or older. There is also a table on the interpretation of microscopy results. Clinical criteria should be used for decisions where urine testing does not support the findings.
Practitioners should assess the risk of serious illness in line with NICE (2007b) guidance on feverish illness in children to ensure appropriate urine tests and interpretation, as both depend on the child’s age and risk of serious illness.
History and examination on confirmed UTI
The guidance recommends that the following risk factors for UTI and serious underlying pathology should be recorded:
- Poor urine flow;
- History suggesting previous UTI or confirmed previous UTI;
- Recurrent fever of uncertain origin;
- Antenatally diagnosed renal abnormality;
- Family history of vesicoureteric reflux or renal disease;
- Dysfunctional voiding;
- Enlarged bladder;
- Abdominal mass;
- Evidence of spinal lesion;
- Poor growth;
- High blood pressure.
NICE makes a range of recommendations to improve the acute management of UTI, but points out that its advice does not address the antibiotic requirements for children not covered by this guidance.
Infants and children with a high risk of serious illness should be referred urgently to the care of a paediatric specialist. Babies under three months with a possible UTI should be referred immediately to a paediatric specialist, and they should be treated with parenteral antibiotics in line with other NICE guidance (NICE, 2007b).
For infants and children aged three months or older with acute pyelonephritis/upper UTI practitioners should:
- Consider referral to a paediatric specialist;
- Treat with oral antibiotics for 7-10 days. The use of an oral antibiotic with low resistance patterns is recommended, for example cephalosporin or co-amoxiclav;
- If oral antibiotics cannot be used, treat with an IV antibiotic such as cefotaxime or ceftriaxone for 2-4 days, followed by oral antibiotics for a total duration of 10 days.
For infants and children aged three months or over who have cystitis/lower UTI healthcare professionals should:
- Treat with oral antibiotics for three days. The choice of antibiotics should be directed by locally developed multidisciplinary guidance. The guidance suggests that trimethoprim, nitrofurantoin, cephalosporin or amoxicillin may be suitable;
- The parents or carers should be advised to bring the infant or child for reassessment if she or he is still unwell after 24-48 hours. If an alternative diagnosis is not made, a urine sample should be sent for culture to identify the presence of bacteria and determine antibiotic sensitivity if urine culture has not already been carried out.
Antibiotic prophylaxis should not be routinely recommended in infants and children following first-time UTI, although it may be considered in those infants and children with recurrent UTI. Asymptomatic bacteriuria in infants and children should not be treated with prophylactic antibiotics (NICE, 2007a).
The guidance advises that imaging after recovery from UTI is targeted to children at highest risk, for example, those under six months or with recurrent UTI. The document includes three tables that detail the imaging schedule, covering different types of imaging at different times, for the following age groups: babies under six months; infants and children six months or older but under three years; and children aged three or over. These tables indicate when children should and should not have imaging tests, and NICE also provides definitions of atypical and recurrent UTI.
INFORMATION FOR CHILDREN AND PARENTS
- Healthcare professionals should ensure that when children are identified as having a suspected UTI, they and their parents/carers as appropriate are given information about the need for treatment, the importance of completing any treatment, and advice about prevention and long-term management;
- Practitioners should ensure that patients and parents/carers are aware of the possibility of a UTI recurring and to seek prompt treatment for any suspected reinfection;
- Patients and/or their parents/carers should be offered advice and information on the following:
- Prompt recognition of symptoms;
- Urine collection, storage and testing;
- Appropriate treatment options;
- The nature of and reason for any urinary tract investigation;
- Reasons and arrangements for long-term management if required.
Source: NICE (2007a).