This is a summary for the latest NICE guidelines published in August 2007 regarding urinary tract infections (UTIs) in children.

1. NICE guidance for
management of
UTIs in childhood
Shady Nafie - FRCS (Urol) VIVA 2018
NICE Guidelines
(August 2007) - CG54

2. 1.1 Diagnosis
Symptoms & Signs:
• <3 months: Fever, Vomiting, Lethargy, Poor feeding, Failure to
thrive, Offensive urine, Haematuria.
• >3 months: Fever, Frequency, Dysuria, Loin pain, Abdominal
pain, Vomiting, Lethargy, Poor feeding, Offensive urine,
Haematuria.
NICE: Send urine sample for analysis in:
• Child with symptoms suggestive of UTI.
• Unexplained fever (38°C) - no obvious source of infection.
• Child with alternative source of infection, doesn't respond to
treatment in 24 hrs.

3. 1.1 Diagnosis
Child
>3 yrs
Leucocytes
+ve -ve
Nitrites
+ve
- Antibiotics
- C&S
- C&S
- Antibiotics
-ve
- C&S
- Antibiotics
(Only if
clinically UTI)
- No UTI
- No Anti
Child
<3 yrs
Leucocytes
+ve -ve
Nitrites
+ve
- C&S
- Antibiotics
- C&S
- Antibiotics
-ve
- C&S
- Antibiotics
- No UTI
- No Anti
Clinical differential between upper/lower tract infections:
• Fever >38 °C + bacteriuria = Pyelonephritis.
• Fever <38 °C + loin pain + bacteriuria = Pyelonephritis.
• Bacteriuria + no systemic symptoms = Cystitis
Collection: Clean catch, Collection pad, Catheter, SPA

4. 1.2 Acute Management
<3 months / high risk of serious illness → Refer to Paediatrics
>3 months:
• Cystitis: Oral antibiotics; 3 days (Trimethoprim, Nitrofurantoin,
Cephalosporins, Amoxicillin), local guidelines.
• Pyelonephritis:
1. Oral antibiotics; 7-10 days (Cephalosporin, Co-Amoxiclav)
2. IV Antibiotics; 2-4 days (Cefotaxime), then Oral antibiotics.
Prophylactic antibiotics in recurrent UTIs. Not routine.
Asymptomatic bacteriuria → No Treatment

5. 1.3 Imaging Tests
UTI Age US (Acute) US (6/52) DMSA (4-6/12) MCUG*
Typical UTI <6 mo Yes
- E. Coli
- Axb response in 48 hrs 6 mo - 3 yrs
>3 yrs
Atypical UTI <6 mo Yes Yes Yes
- Severely unwell
- Non E. Coli
- No response in 48 hrs
- Septicaemia
- Poor flow, Abdo mass
- Raised Creatinine
6 mo - 3 yrs Yes Yes Consider**
>3 yrs Yes
Recurrent UTI <6 mo Yes Yes Yes
- x3 Cystitis
- x2 Pyelonephritis
- One of each
6 mo - 3 yrs Yes Yes Consider**
>3 yrs Yes Yes
*Some centres prefer MAG3 with indirect cystogram, if VUR is suspected.
**If dilatation on USS, poor flow, non E.Coli infection, family history of VUR.

6. 1.4 Surgical Intervention
Surgical management of VUR is not routinely recommended.
Medical (conservative)
• Good fluid intake.
• Frequent voiding.
• Prophylactic antibiotics (decrease UTI risk by 30%).
Surgical
• Indications:
breakthrough infections.
difficulty adhering to medical treatment.
• Types:
Cystoscopy + DEFLUX injection (80% success).
Re-implantation.

7. 1.5 Follow up
No need for follow up:
• Typical UTI.
• Normal investigations.
• Asymptomatic bacteriuria.
Follow up by Paediatric Specialist:
• Abnormal imaging.
• Recurrent UTIs.
Follow up by Paediatric Nephrologist:
• Parenchymal abnormalities on imaging.
• Impaired kidney function.
• Raised BP.
• Proteinuria.

8. 1.6 Advice for children & parents
Important to complete course of treatment.
Important to seek help if suspect re-infection.
Healthcare professionals should provide information regarding:
• Recognition of symptoms.
• Urine collection.
• Treatment options.
• Prevention.
• Prognosis.
• Long term management if required.