Urinary tract infection in children

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Urinary tract infection in children
Implementing NICE guidance
2007
NICE clinical guideline 54
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Changing clinical practice

• NICE guidelines are based on the best available
  evidence
• The Department of Health asks NHS organisations
  to work towards implementing guidelines
• Compliance with developmental standards will be
  monitored by the Healthcare Commission

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What this presentation covers

• Background
• Key recommendations
• Implementation advice
• Costs and savings
• Resources from NICE

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Backgroundwhy this guideline matters

• Urinary tract infection (UTI) is common in
  infants and children
• UTI is difficult to recognise
• Collecting urine and interpreting laboratory
  results is not easy
• Diagnosis is not always confirmed
• UTI in infants and children may have long-term
  sequelae

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What the guideline covers

• Diagnosis
• assessing signs and symptoms
• urine collection and testing
• Management
• antibiotic treatment
• Imaging
• Follow-up
• Information and advice

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Key recommendations

• Symptoms and signs
• Urine collection
• Urine testing
• History and examination
• Acute management
• Antibiotic prophylaxis
• Imaging tests

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Assess the symptoms and signs

• Test urine when an infant or child presents with
• unexplained fever of 38C or higher
• or
• symptoms and signs suggestive of UTI
• Consider testing urine when an infant or child
  presents with
• an alternative site of infection, but remains
  unwell
• Do not test urine when an infant or child
  presents with
• an obvious alternative source of fever

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Presenting symptoms and signs in infants and
children with UTI

• Younger than 3 months fever, vomiting, lethargy,
  irritability, poor feeding, failure to thrive,
  abdominal pain, jaundice, haematuria, offensive
  urine
• 3 months or older and preverbal fever,
  abdominal pain, loin tenderness, vomiting, poor
  feeding, lethargy, irritability, haematuria,
  offensive urine, failure to thrive
• 3 months or older and verbal frequency, dysuria,
  dysfunctional voiding, changes to continence,
  abdominal pain, loin tenderness, fever, malaise,
  vomiting, haematuria, offensive or cloudy urine

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Urine collection and testing

• A clean catch urine sample is the recommended
  method for urine collection
• If a clean catch sample is unobtainable, use
  other non-invasive methods, such as urine
  collection pads
• Do not use cotton wool balls, gauze or sanitary
  towels to collect urine
• Catheter samples or suprapubic aspiration (SPA)
  should be used when urine collection is not
  possible by non-invasive methods
• Where there is a high risk of serious illness, do
  not delay treatment if a urine sample is
  unobtainable

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Urine collection and testing suprapubic
aspiration (SPA)

• Use suprapubic aspiration only when urine
  collection is not possible by non-invasive
  methods
• Ultrasound guidance should be used to demonstrate
  urine in the bladder before SPA is attempted

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Urine collection and testing infants younger
than 3 months

• Refer immediately to paediatric specialist care,
  where a urine sample should be sent for urgent
  microscopy and culture as part of the septic
  screen carried out prior to treatment
• These infants should be managed in accordance
  with the recommendations for this age group in
  Feverish illness in children (NICE clinical
  guideline 47).

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Urine collection and testing infants and
children aged 3 months to 3 years

• If the infant or child presents with specific
  urinary symptoms
• Urgent microscopy and culture is the preferred
  method for diagnosing UTI. After a urine sample
  is obtained, antibiotic treatment should be
  started. If urgent microscopy is not available,
  send a urine sample for microscopy and culture.
• If the infant or child presents with symptoms
  that are non-specific to UTI
• Urgent microscopy and culture is the preferred
  method for diagnosing UTI, but for infants and
  children with an intermediate risk of serious
  illness, when this is not available, dipstick
  testing for leucocytes and nitrite may be used.

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Urine collection and testing children 3 years
and older

• Perform a dipstick test for leukocyte esterase
  and nitrite.
• If both are positive, start antibiotic treatment
  and if there is risk of serious illness and/or
  history of UTI, send a urine sample for culture.
• If only nitrite is positive, start antibiotic
  treatment and send a urine sample for culture.
• If only leukocyte esterase is positive, send a
  urine sample for microscopy and culture. Start
  antibiotic treatment for UTI only if there is
  good clinical evidence of UTI.

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Determine location
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History and examination risk factors to identify

• Poor urine flow or dysfunctional voiding
• Previously suggested or confirmed UTI
• Recurrent fever of uncertain origin
• Antenatally-diagnosed renal abnormality
  
  
  
  
  
• Family history of vesicoureteric reflux or renal
  disease
• Constipation
• Dysfunctional voiding
• Enlarged bladder
• Abdominal mass
• Evidence of spinal lesion
• Poor growth
• High blood pressure

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Antibiotic treatment infantsyounger than 3
months

• Refer immediately to paediatric specialist when
  UTI suspected
• The treatment is parenteral antibiotics in line
  with the NICE guideline Feverish illness in
  children (clinical guideline 47)

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Antibiotic treatment infants and children3
months and older

• Acute pyelonephritis/upper urinary tract
  infection
• Consider referral to a paediatric specialist
• Treat with oral antibiotic, such as cephalosporin
  or co-amoxiclav, for 7-10 days
• If oral antibiotics cannot be used, give
  parenteral antibiotic treatment in line with the
  NICE guideline Feverish illness in children
  (clinical guideline 47)

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Antibiotic treatment infants and children3
months and older

• Cystitis/lower urinary tract infection
• Treat with oral antibiotics for 3 days
• Trimethoprim, nitrofurantoin, cephalosporin
• or amoxicillin may be suitable
• Re-assess if infant or child remains unwell
  after
• 24-48 hours. If no alternative diagnosis is made,
  
• send urine sample for culture to identify
  presence of
• bacteria and determine antibiotic sensitivity
• (if this has not already been done)

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Antibiotic prophylaxis

• Prophylactic antibiotics have been used on the
  assumption that they prevent further infections
  that may be associated with systemic illness and
  thus avoid subsequent renal damage. However,
  further evaluation is needed.
• Antibiotic prophylaxis should not be routinely
  recommended following first-time UTI.

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Imaging tests recurrent UTI

• The use of imaging will depend on the age of the
  child and on whether the UTI is recurrent or
  atypical.
• Recurrent UTI is defined as
• Two or more episodes of UTI with acute
  pyelonephritis/upper urinary tract infection, or
• One episode of UTI with acute pyelonephritis/uppe
  r urinary tract infection plus one or more
  episodes of UTI with cystitis/lower urinary tract
  infection, or
• Three or more episodes of UTI with
  cystitis/lower urinary tract infection

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Imaging tests atypical UTI

• Atypical UTI is defined as any of the following
• Seriously ill (for more information refer to
  Feverish illness in children (NICE clinical
  guideline 47)
• 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.

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Imaging
Recommended imaging schedule for infants younger
than 6 months

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Imaging

Recommended imaging schedule for infants and
children 6 months and older but younger than
3 years
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Imaging
Recommended imaging schedule for children 3
years and older
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Implementation advice

• Feedback to NICE suggests that there are likely
  to be four key areas for successful
  implementation
• Diagnosis
• Training and equipment
• Communication
• Research and audit

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Action plan diagnosis

• Collaboration between microbiology laboratories,
  radiology departments and primary care teams will
  help to ensure that the guideline recommendations
  are integrated into all relevant protocols
• Put systems into place to prevent delays in the
  delivery of urine samples outside office hours
• If one does not already exist, set up a contract
  with microbiology services in which it is agreed
  that microscopy and culture will be performed
  outside office hours when necessary, and that GPs
  will be informed of the results via telephone

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Action plan training and equipment

• Ensure that the equipment and skills needed to
  collect and test urine samples are available in
  your setting
• Ensure that the equipment and skills needed to
  assess risk factors are available in your
  setting. If this is not possible, ensure there
  are alternative protocols for assessment of
  infants and children by a suitably trained
  professional
• Consider extending training in urgent microscopy
  to paediatric AE staff

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Action plan communication

• Ensure that records are updated when there is
  confirmation of UTI, and that an alert mechanism
  is in place to indicate when an infant or child
  has been diagnosed with UTI in the past
• Ensure that care protocols include arrangements
  for follow-up of the results of urgent microscopy
  tests. Consider patient recall systems to
  facilitate prompt follow-up of patients whose
  urgent microbiology results indicate a need for
  treatment

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Action plan communication

• Review protocols to ensure that information is
  provided to parents and carers about the
  treatment and care of infants and children with
  UTI
• Work with colleagues to incorporate guideline
  changes into joint formularies between primary
  and secondary care
• Engage with your prescribing adviser to ensure
  that information on new prescribing is
  disseminated to pharmacists and to general
  practices

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Action plan research and audit

• Consider participating in pilot studies to
  tackle research recommendations highlighted in
  the guideline
• Consider participating in suitable audit projects
  to assess the effect of the guideline
  recommendations in practice  
• Incorporate the NICE audit criteria into local
  audit templates to ensure that prescribing
  protocols are fulfilled and to check whether UTI
  has been identified as lower or upper tract

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Costs and savings
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Resources from NICE

• Implementation advice
• Costing tools
• costing report
• costing template
• Audit criteria
• www.nice.org.uk/CG54

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Access the guideline online

• Quick reference guide a summary
• NICE guideline all of the recommendations
• Full guideline all of the evidence and
  rationale
• Understanding NICE guidance a version for
  patients and carers
• www.nice.org.uk/CG54