UTIs in Children

Question 1

What symptom is most associated with UTIs in children? (GP update UTI in children)

Answer 1

Crying or pain on feeling the need/urination.

Question 2

What are the 3 tests used to investigate UTIs and how are they useful?

Answer 2

1/ USS - cheap, no radiation and can detect the presence of most congenital abnormalities but NOT effective at detecting mild to moderate vesicoureteric reflux. Do during infections.

2/ Micturating Cystourethrography(MCUG) - Gold standard test for detecting vesicoureteric reflux. Only recommended for infants younger than 6 months with atypical or recurrent infections.

3/ Dimercaptosuccinic Acid Scan (DMSA) - Gold standard test for detecting renal scarring or renal parenchymal damage. NICE recommend this should be done 4-6m after infection.

Question 3

What is the definition of a complicated UTI?

Answer 3

UTI associated with serious illness/septicaemia, abdo mass etc.

Question 4

What is the definition of an atypical UTI?

Answer 4

Any non-E.Coli infections and should have an USS at the time of infection.

Question 5

What is the definition of an recurrent infection?

Answer 5

Recurrent UTI = ≥2 UTIs including at least 1 episode of upper UTI/pyelonephritis, or ≥3 lower UTIs

Question 6

What are some features suggestive of an atypical infection?

Answer 6

• Seriously ill
• 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

Question 7

What percentage of children who have a confirmed UTI will have vesicoureteric reflux?

Answer 7

25-40%. It is a common cause of UTI in children.

Question 8

When child needs investigation for UTI what can you write on the request form?

Answer 8

“child aged 2y with 3x UTI: please arrange relevant tests.”

Question 9

What Antibiotics should be prescribed in a childhood UTI?

Answer 9

NICE recommends a 3 day course of trimethoprim, nitrofurantoin, amoxicillin or cephalosporin.

(Trimethoprim is cheap)

Question 10

How do you manage a typical UTI in a child (<6m, 6m-3y & >3yrs)

Answer 10

Typical UTI that responds in 48 hours

• < 6 months – US within 6 weeks.
• 6m-3y – No investigation needed.
• >3y – No investigations needed.

Question 11

How do you manage an atypical UTI in a child (<6m, 6m-3y & >3yrs)

Answer 11

Atypical UTI

• < 6 months – US during infection & DMSA & MCUG OP.
• 6m-3y – US during infection & DMSA 4-6 months later.
• >3y – US during infection.

Question 12

How do you manage recurent UTIs in a child? (<6m, 6m-3y & >3yrs)

Answer 12

Recurrent UTI

• < 6 months – US during infection. DMSA & MCUG OP.
• 6m-3y – US & DMSA OP
• >3y – US & DMSA OP.

Question 13

When an MCUG is performed what should be given?

Answer 13

Oral antibiotics for 3 days with the MCUG taking place on the second.

Question 14

When should a Urine microscopy and culture be sent?

Answer 14

1. Children <3years old - urgently if possible.
2. Children of any age if there is no response to empirical antibiotics after 24 - 48 hours

Question 15

How do you diagnose a UTI in children age 3 and above?

Answer 15

Children aged 3 and older: Use urine dipstick to diagnose UTI.

Question 16

When should a child be referred urgently?

Answer 16

• All infants with suspected UTI (presents with fever, vomiting, lethargy, irritability)
• A child of any age who is acutely unwell
• Child >3 months of age with acute pyelonephritis/upper UTI and unable to tolerate oral antibiotics

Question 17

What are the symptoms of pyelonephritis in children and how can you treat it?

Answer 17

• Treat upper UTI with co-amoxiclav for 7-10 days (or as per local guidelines)
• Bacteriuria, loin pain/tenderness and fever of ≥38C

Question 18

When should a child be routinely referred?

Answer 18

• Recurrent UTI
• Abnormal imaging.

Question 19

How do you manage symptomatic and asymptomatic UTIs in children

Answer 19

• Symptomatic
  
  • UTI - Trimethoprim, Amoxicillin or Nitrofurantoin.
  • Pyelonephritis - Co-amoxiclav
• Asymptomatic
  
  • Only treat if nitrite positive.

Question 20

If a child is 3 years and over and the urine dip is leucocytes and nitrite positive, how should you treat it?

Answer 20

1. Start antibiotics
2. Send MC&S if unwell

Question 21

If a child is 3 years and over and the urine dip is leucocytes -ve and nitrite positive, how should you treat it?

Answer 21

1. Start antibiotic if fresh sample tested (within 4hours), and send for culture.

Question 22

If a child is 3 years and over and the urine dip is leucocytes +ve and nitrites negatives, how should you treat it?

Answer 22

1. Send sample for microscopy and culture and treat on basis of results
2. Only start Abx if there is good evidence of UTI–may indicate infection elsewhere

Question 23

In infants, <6 months old, what imaging do you organize?

Answer 23

• Typical UTI -follow up US within 6 weeks of a treated infection.
• If complicated/atypical infection, US at the time of infection and F/U DMSA and MCUG.

Question 24

In infants, 6 months to 3 years old, what imaging do you organize?

Answer 24

• Only require imaging/referral if they have an atypical or recurrent UTI
  
  • Atypical UTI - US during infection, and follow-up DMSA.
  • Recurrent UTI - US and DMSA, and Referral.

Question 25

In infants, >3 years old, what imaging do you organize?

Answer 25

• Typical UTI - nothing required.
• Atypical UTI - US during infection
• Recurrent UTI - Non-urgent US and DMSA

Question 26

When should antibiotic prophylaxis be considered in children for UTIs?

Answer 26

Recurrent UTIs.