Urinary Tract Infections in

Children
Dr May Loong Tan
RCSI & UCD Malaysia Campus
Learning Objectives:
• Identification and management of UTI in children
• By the end of the module, you should be able to know:
• The various presentations of UTI
• Diagnosis and investigation of children with UTI
• Urine sample collection
• Interpretation of urine tests
• Selection of antibiotics for children with UTI
• Causes of recurrent UTI
Case 1
• 3-week old girl, born at term with a birthweight of 2500gm. Noted
jaundice on Day 3 of life, levels not high enough for phototherapy.
Fully breastfed. Jaundice persisted, at Day 15 of life, serum bilirubin
was 150mmol/l. Examination revealed no abnormality.
• This week baby refused feeding. Current weight 2600gm. Serum
bilirubin remained around 150 mmol/l (unconjugated).
Case 2
• 8 month old boy, previously well. Presented with sudden onset of
high grade fever. No respiratory symptom. Passed 2 to 3 loose stools
per day over the past 2 days. No vomiting.
• On examination, temperature was 39.8°C. Ears and throat were
normal. All other examination normal.
Case 3
• 9 year old girl complained of burning sensation during micturition.
She had one episode of nocturnal enuresis.
• No other complaints.
• On examination, her temperature was 37.5°C. No abdominal
tenderness.
In which of these cases is UTI considered?
Neonate with
Infant with high
prolonged jaundice
grade fever
and poor weight
without a source
gain

Child with urinary

symptom but no
fever
Diagnosis of UTI
• Gold standard:
• Urine culture
• Quality of urine collected is very important
• Quality depend on:
• Method of collection
• Storage & Transport
• Must be cultured within 4 hours of collection
• If more than 4 hours is expected, store at 4°C (refrigerate, not freeze)
 Urine collection in children
Neonates, infants and non continent children Older children and continent
children
Clean catch sample
• Mid-stream urine

Urine collection bag

Suprapubic tap Bladder catheterization

 Diagnosis of UTI: what about urine test strips?

• Simple, fast and

cost effective
• Screening test
• Sensitivity and
specificity
• Combined with
urine culture
NICE UK Guidelines (2018 update)

LE + NT + UTI

UTI
LE - NT + (if sample
fresh)

Wait
LE + NT - for
culture

Not
LE - NT -
UTI
Why are nitrites positive in UTI?
• Nitrite tests detect the products of nitrate reductase, an enzyme
produced by many bacterial species.
• A positive result on the nitrite test is highly specific for UTI, typically
because of urease-splitting organisms, such as Proteus species and,
occasionally, E coli.
Definitions of atypical and recurrent UTI
• Atypical UTI includes:
• seriously ill (for more information refer to the NICE guideline on fever in under 5s)
• 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
• Recurrent UTI:
• 2 or more episodes of UTI with acute pyelonephritis/upper urinary tract infection, or
• 1 episode of UTI with acute pyelonephritis/upper urinary tract infection plus one or more
episode of UTI with cystitis/lower urinary tract infection, or
• 3 or more episodes of UTI with cystitis/lower urinary tract infection
Management
• All UTIs are treated with antimicrobials
• Intravenous: neonates, infants, very ill, pyelonephritis, atypical
• Oral: older children, no other risks

• Prevention:
• Risk factors: Neurogenic bladder, renal tract anomalies
• No risk factors:
• Avoid constipation
• Hygiene
• Prophylactic antibiotics only for selected patients with risk factors
Imaging (Malaysian Guidelines)
• Ultrasound
• All children < 3 years old with confirmed UTI
• Children > 3 years old if atypical or recurrent UTI
• DMSA (Dimercaptosuccinic acid) scan
• Nuclear isotope uptake scan. Good for picking up renal scars
• Only atypical or recurrent UTI (all ages)
• MCUG (Micturating cystoureterogram)
• Diagnosis of vesiculoureteric reflux (VUR)
• Infants with atypical or recurrent UTI
• Children < 3 years if abnormal ultrasound, family history of VUR, atypical
organism
NICE 2018 Guidelines
Comparing Malaysian Guidelines and NICE
Malaysian NICE
Under 6 months Not specified. Ultrasound (all types of UTI, timing
depends on type of UTI).
DMSA – atypical or recurrent UTI
MCUG –atypical or recurrent
Under 3 years Ultrasound (all) Ultrasound – only atypical or
DMSA – atypical or recurrent UTI recurrent UTI
MCUG – abnormal USG or atypical DMSA – atypical or recurrent UTI
organism or family history MCUG – abnormal USG or atypical
organism or family history
Above 3 years old No, unless atypical or recurrent No, unless atypical or recurrent
DMSA – atypical or recurrent UTI (timing stated)
MCUG – Not needed DMSA –recurrent UTI only
MCUG – Not needed
Back to our 3 cases
Neonate with prolonged
Infant with high grade Child with urinary
jaundice and poor weight
CASE fever without a source symptom but no fever
gain

URINE COLLECTION

TREATMENT

IMAGING