UTI is the one of the most common infections in children. It is not difficult to diagnose this due to characteristic symptoms and non-invasive investigations, however this does need to be treated timely and effectively to avoid any later long term harm to Kidneys, more so for young children.
How does it present?
The presentation can be often nonspecific in infancy including vomiting, diarrhoea, loss of appetite and weight, and being irritable. It is very important in this age to get the baby checked if you feel your baby is not well for an unknown reason.
In older children after infancy, it usually presents with pain in passing urine, fever (usually above 38 degree centigrade), and/or feeling generally unwell. It can be associated with other symptoms including pain abdomen/flanks, vomiting, loss of appetite etc.
In adolescence and older age groups it can present with localised symptoms such as Cystitis, an inflammation of bladder only when person would be well, but have pain in passing urine.
How is it diagnosed?
Clinical presentation is usually quite specific to lead the clinician to diagnosis. This can further be supported with other simple investigations such as dipping the urine sample for pus cells, and Nitrite, an enzyme present due to bacteria. The gold standard of investigation is stil to culture the urine in laboratory to see which bacteria is causing the infection if any. And what antibiotic it is sensitive to.
Sometimes, further investigations may be needed including an Ultrasound of Kidneys/Bladder, and other special type of X-rays, more so for younger children.
How is it treated?
UTIs are often easy to treat with 1st line antibiotics, and the length of antibiotic is often short for less than a week. It is important to make a right choice of antibiotic though, based on the culture, and population characteristic.
What precautions I may take to avoid it?
UTI is often precipitated due to poor bladder habits, lack of hygiene, constipation, and poor liquid intake.
Parents should encourage their children to drink at least 6-8 glasses of clear liquid every day, empty bladder regularly during day time, have a regular bowel habit with soft stool, and maintain a good hygiene. I often advise for daily shower/bath at least once a day if possible.
UTI in Children - Myths & Facts
Is it a UTI or not?
Many of the referrals are based on the symptoms of dysuria along with positive urine culture/dipsticks which unfortunately can sometimes be due to a contaminated sample.
Making a diagnosis of UTI, it is very important to make sure that patient is having specific symptoms too. NICE Guidance allows primary care to diagnose UTI on basis of dipsticks; however urine culture is still the gold standard for confirmation of UTI.
So, what are the symptoms of UTI?
The recent NICE guideline has outlined the most common to least common symptoms in the beginning of UTI algorithm. However this does not specify which symptom is more specific to urinary tract. Though dysuria may be the commonest symptom for UTI,
It is more commonly produced by a local infection at vulvo-vaginal /prepuce area. Fever along with dysuria and/or other symptoms such as increased frequency, urgency, haematuria, secondary enuresis, pain abdomen and loin pain is strongly suggestive of UTI in a chid after the age of infancy. Absence of fever raises a suspicion on the diagnosis after infancy, however older children and adolescents can present just with symptoms of cystitis. The symptoms can be very non-specific in infancy period.
Where is the UTI?
It is very important to decide on the location of UTI if clinically suspected. An upper UTI involving Kidneys can damage the kidneys soon if not picked up very early. Mostly the symptom suggesting an upper UTI is loin pain in presence of other symptoms and fever.
A child looking unwell with high fever and other symptoms suggesting UTI should always be suspected of having an upper UTI unless proven. Though NICE suggests upper UTI can be treated with oral antibiotics, it can be argued to treat them aggressively with initial parenteral antibiotic if child is unwell, especially within a secondary setting.
What type of UTI?
NICE suggest 3 types of UTIs-simple, atypical and recurrent. Simple UTI is a UTI which is a lower UTI (not involving kidneys), responds within 48 hours of starting treatment and caused by E.coli. Simple UTIs usually do not need any investigations other than urine culture after the age of infancy. It becomes atypical if child does not respond within 48 hours, is unwell, shows a non-E.coli organism in the urine culture, has got impaired kidney function or got abdominal mass. This may need further imaging of kidney tract.
Recurrent UTI is one when a child has suffered with at least 2 upper UTI, 1 upper UTI and 2 or lower UTI or more than 3 lower UTIs. NICE does not specify a time limit within which these recurrences should happen. However there are recent guidelines from other sources suggesting the recurrence to happen within 1 year.
How to prove diagnosis of UTI?
Once clinically suspected, it is important to prove it on a urine culture. NICE suggests that dipstick test of a urine sample should be enough to diagnose or rule out UTI in a child over 3 years. However a dipstick test can be falsely negative if child has got increased frequency of micturition allowing urine less time to produce the reaction with nitrite. On the other hand, dipsticks are mostly positive with blood and leukocytes in a child presenting with local inflammation of urethral/Volvo-vaginal area. Hence it is important to consider the findings on dipsticks carefully in context of general wellbeing of child, and other signs/symptoms.
A positive urine culture taken on a clean catch urine sample is the gold standard for making a diagnosis of UTI. However it can be false positive if urine was not collected in a clean catch manner, or left outside in room temperature for too long.
How to collect a clean –catch urine sample?
This sounds easy. Unfortunately it can often be the most daunting task, especially in young girls. There is unfortunately not much guidance available on how to collect a urine sample. Parents mostly collect it without cleaning the perineum and the urine can either be trickling through the perinea skin or transferred in the sterile pot after being collected in a contaminated pot. There are urine sterile pots available now-a-days attached with a funnel.
It is important that child should first be cleaned around the perineum with a clean cotton wool soaked in clean water, and then mid-stream urine should be collected going directly in the sterile pot without touching the skin around. For boys, the prepuce should be retracted (if possible) and glans cleaned before taking the sample. The inside of pot or funnel should not come in contact with any part of skin.
Prepuce is the most common place for organisms like proteus /pseudomonas to colonise. If prepuce not retracted and cleaned, urine is mostly showing the bug as a result of contamination.
A collection on urine bags/pads can be okay for a dipstick test, especially if the threshold of UTI diagnosis is low. However a culture should never be done on a bag//pad urine due to risk of contamination.
How should it be treated?
Most of the UTIs are fortunately a lower simple UTI. Once suspected, oral antibiotic should be started after collecting a clean catch urine sample to be sent to laboratory. The choice of antibiotics depends on the local policy. However the commonest antibiotic to be started pending culture is Trimethoprim, Nitrofurantoin or Cephalexin. A course of 3 to 5 days is usually sufficient for a lower simple UTI.
An upper UTI should be more aggressively treated for at least 7 to 10 days.
A UTI in a baby less than 3 months of age always warrants intravenous antibiotics. The choice of antibiotic is either Cefotaxime/Cefuroxime in 1 to 3 months old and Benzylpennicilin and Gentamycin in neonates. This group of children need referral to secondary care.
The previous guideline recommended imaging every child with UTI. Due to growing concerns about over-investigation, NICE now has spoken of a very limited area for these investigations:
The imaging recommended are :
Children less than 6 months are recommended for having a kidney ultrasound to rule out congenital abnormalities and any gross structural problem with kidneys. Children with atypical/Recurrent UTI in less than 6 months age need a DMSA and MCUG to rule out the possibility of any scarring secondary to investigation and a vesico-ureteric reflux respectively.
Children more than 6 months of age do need ultrasound kidney and DMSA if they suffer with atypical /recurrent UTI. MCUH has got a very limited role after infancy.
Children after achieving the continence and having atypical UTI need ultrasound and ultrasound kidney and DMSA if recurrent UTI. However it is important to make the diagnosis of recurrent UTI carefully. I find many child presenting with recurrent vulvo-vaginits/ balanitis being diagnosed of recurrent UTI on basis of positive urine culture which was done on a non-clean sample.
Children other than having a simple UTI should be referred to a specialist to decide on these investigations.
What about prophylaxis?
NICE does not recommend for antibiotic prophylaxis as a routine now. However it should be considered in a child with recurrent UTI.
How about parent education?
UTI can be recurrent if the risk factors are not taken care off. The commonest predisposing factor to cause UTI is poor bladder habit. Children often have a tendency to hold urine at school or home. Parents should be advised to educate children emptying their bladder every 2 to 4 hourly. Regular drinking is equally important and children should be advised to drink at least 6 to 8 glasses of water or equivalent drink (not fizzy drinks).Poor hygiene is another risk factor. UTI is an opportunistic infection and the comments organism is coming from GI tract. This is more common in girls where the urethra is in close proximity of back passage. A poor wiping habit after attending to toilet (back to front) can bring bugs towards urethra. Regular hygiene helps flushing these organisms away.
The other risk factor to take care of is constipation. A loaded rectum presses on bladder limiting the emptying. The residual urine is susceptible for infection. Parents should be educated to recognise UTI recurrence early so that they can take medical advice soon.
What are the criteria for referral to specialist?
It very much depends on your individual needs and concern. However following conditions in association with UTI are recommended for a referral to specialist for further evaluation of the child: