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Urinary tract infection in children overview

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Urinary tract infection in children HAI

About

What is covered

This pathway covers the diagnosis, treatment and management of urinary tract infections in children.
UTI is a common bacterial infection causing illness in infants and children. It may be difficult to recognise UTI in children because the presenting symptoms and signs are non-specific, particularly in infants and children under 3 years. Current management, which includes imaging, prophylaxis and prolonged follow-up, has placed a heavy burden on NHS primary and secondary care resources. It is costly, based on limited evidence and is unpleasant for children and distressing for their parents or carers. The aim of this pathway is to achieve more consistent clinical practice, based on accurate diagnosis and effective management.

Updates

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on urinary tract infection in children.
NICE has also written a document for patients and the public explaining its quality standard for urinary tract infection in infants, children and young people under 16.

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Updates to this pathway

21 February 2014 Minor maintenance update
16 July 2013 Urinary tract infection in infants, children and young people under 16 quality standard added to the pathway, and minor maintenance updates.
5 June 2013 Update to change clinical guideline 47 links to Feverish illness in children pathway.
26 February 2013 Minor maintenance updates.

Short Text

The diagnosis, treatment and management of urinary tract infections in children

What is covered

This pathway covers the diagnosis, treatment and management of urinary tract infections in children.
UTI is a common bacterial infection causing illness in infants and children. It may be difficult to recognise UTI in children because the presenting symptoms and signs are non-specific, particularly in infants and children under 3 years. Current management, which includes imaging, prophylaxis and prolonged follow-up, has placed a heavy burden on NHS primary and secondary care resources. It is costly, based on limited evidence and is unpleasant for children and distressing for their parents or carers. The aim of this pathway is to achieve more consistent clinical practice, based on accurate diagnosis and effective management.

Sources

The NICE guidance that was used to create the pathway.
Urinary tract infection in children. NICE clinical guideline 54 (2007)

Quality standards

Urinary tract infection in infants, children and young people under 16 quality standard

These quality statements are taken from the urinary tract infection in infants, children and young people under 16 quality standard. The quality standard defines clinical best practice for urinary tract infection in infants, children and young people under 16 and should be read in full.

Quality statements

Presentation with unexplained fever of 38°C or higher

This quality statement is taken from the urinary tract infection in infants, children and young people under 16 quality standard. The quality standard defines clinical best practice for urinary tract infection in infants, children and young people under 16 and should be read in full.

Quality statement

Infants, children and young people presenting with unexplained fever of 38°C or higher have a urine sample tested within 24 hours.

Rationale

It is important that a urinary tract infection is considered as a cause of feverish illness in infants, children and young people. When an infant, child or young person (under 16 years) presents to a healthcare practitioner with a temperature of 38°C or higher, and there is no obvious source of the infection, a urine sample should be tested within 24 hours to ensure prompt diagnosis and antibiotic treatment if appropriate.

Quality measures

Structure
Evidence of local arrangements to ensure that infants, children and young people (under 16 years) who present with unexplained fever of 38°C or higher have a urine sample tested within 24 hours.
Data source: Local data collection.
Process
Proportion of infants, children and young people who present with unexplained fever of 38°C or higher who have a urine sample tested within 24 hours.
Numerator: the number of people in the denominator who have a urine sample tested within 24 hours.
Denominator: the number of infants, children and young people (under 16 years) presenting with unexplained fever of 38°C or higher.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers ensure that systems are in place for infants, children and young people presenting with unexplained fever of 38°C or higher to have a urine sample tested within 24 hours.
Healthcare practitioners ensure that infants, children and young people presenting with unexplained fever of 38°C or higher have a urine sample tested within 24 hours.
Commissioners ensure that they commission services for infants, children and young people presenting with unexplained fever of 38°C or higher that carry out testing of urine samples within 24 hours.

What the quality statement means for patients and carers

Infants, children and young people under 16 with a temperature of 38°C or higher and no obvious infection have a urine sample tested within 24 hours of seeing a healthcare professional.

Source guidance

NICE clinical guideline 54, recommendations 1.1.1.1 and 1.1.5.1 (key priorities for implementation).

Definitions of terms used in this quality statement

Although all infants, children and young people with symptoms and signs suggesting urinary tract infection should have a urine sample tested for infection, this statement relates specifically to those presenting with unexplained fever of 38°C or higher.
A urinary tract infection may be the cause of fever if there is no obvious source of infection and there is no alternative diagnosis.
NICE clinical guideline 54 recommends urine-testing strategies according to 3 separate age groups. The urine-testing strategies are grouped as follows:
  • infants younger than 3 months (table 2 in the NICE guideline)
  • infants and children 3 months or older but younger than 3 years (table 3 in the NICE guideline)
  • children 3 years or older (table 4 in the NICE guideline).
Assess the risk of serious illness in line with NICE clinical guideline 160 to ensure appropriate urine tests and interpretation, both of which depend on the child's age and risk of serious illness.

History and examination – recording of risk factors

This quality statement is taken from the urinary tract infection in infants, children and young people under 16 quality standard. The quality standard defines clinical best practice for urinary tract infection in infants, children and young people under 16 and should be read in full.

Quality statement

Infants, children and young people with a urinary tract infection have risk factors for urinary tract infection and serious underlying pathology recorded as part of their history and examination.

Rationale

Presenting symptoms, findings on examination, results of urine testing and knowledge of risk factors are all important when a diagnosis of urinary tract infection is being considered. Recording of risk factors is a cumulative process as part of the history and examination of an infant, child or young person with a urinary tract infection. Recording of risk factors is also important in order to identify whether onward referral and further investigations will be needed.

Quality measures

Structure
Evidence of local arrangements to ensure that infants, children and young people (under 16 years) with a urinary tract infection have risk factors for urinary tract infection and serious underlying pathology recorded as part of their history and examination.
Data source: Local data collection.
Process
Proportion of infants, children and young people with a urinary tract infection who have risk factors for urinary tract infection and serious underlying pathology recorded as part of their history and examination.
Numerator: the number of people in the denominator who have risk factors for urinary tract infection and serious underlying pathology recorded as part of their history and examination.
Denominator: the number of infants, children and young people (under 16 years) with a urinary tract infection.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers ensure that systems are in place for infants, children and young people with a urinary tract infection to have risk factors for urinary tract infection and serious underlying pathology recorded as part of their history and examination.
Healthcare practitioners ensure that infants, children and young people with a urinary tract infection have risk factors for urinary tract infection and serious underlying pathology recorded as part of their history and examination.
Commissioners ensure that they commission services for infants, children and young people with a urinary tract infection where risk factors for urinary tract infection and serious underlying pathology are recorded as part of their history and examination.

What the quality statement means for patients and carers

Infants, children and young people under 16 with a urinary tract infection have any factors that may put them at risk of urinary tract infection and of more serious underlying conditions recorded in their patient notes.

Source guidance

NICE clinical guideline 54, recommendation 1.1.7.1 (key priority for implementation).

Definitions of terms used in this quality statement

NICE clinical guideline 54 recommends that the following risk factors for a urinary tract infection (UTI) and serious underlying pathology should be recorded as part of history and examination on confirmed UTI:
  • poor urine flow
  • history suggesting previous UTI or confirmed previous UTI
  • recurrent fever of uncertain origin
  • antenatally-diagnosed renal abnormality
  • family history of vesicoureteric reflux (VUR) or renal disease
  • constipation
  • dysfunctional voiding
  • enlarged bladder
  • abdominal mass
  • evidence of spinal lesion
  • poor growth
  • high blood pressure.

Information about recognising re-infection

This quality statement is taken from the urinary tract infection in infants, children and young people under 16 quality standard. The quality standard defines clinical best practice for urinary tract infection in infants, children and young people under 16 and should be read in full.

Quality statement

Children and young people who have had a urinary tract infection are given information about how to recognise re-infection and to seek medical advice straight away.

Rationale

Some children and young people will experience a recurrence of urinary tract infection, and it is important that such infections are recognised and treated quickly to reduce the risk of complications.
Children and young people (and parents and carers) should be aware of the importance of seeking medical advice straight away if they think there is another urinary tract infection.

Quality measure

Structure
Evidence of local arrangements to ensure that children and young people (under 16 years) who have had a urinary tract infection are given information about how to recognise re-infection and to seek medical advice straight away.
Data source: Local data collection
Process
Proportion of children and young people who have had a urinary tract infection who receive information about how to recognise re-infection and to seek medical advice straight away.
Numerator: the number of people in the denominator who receive information about how to recognise re-infection and to seek medical advice straight away.
Denominator: the number of children and young people (under 16 years) who have had a urinary tract infection.
Data source: Local data collection.
Outcome
Patient satisfaction with information received about how to recognise re-infection and to seek medical advice straight away.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers ensure that systems are in place to give children and young people who have had a urinary tract infection information about how to recognise re-infection and to seek medical advice straight away.
Healthcare practitioners give information to children and young people who have had a urinary tract infection, and/or their parents or carers, about how to recognise re-infection and to seek medical advice straight away.
Commissioners ensure that they commission services in which children and young people who have had a urinary tract infection, and/or their parents or carers, are given information about how to recognise re-infection and to seek medical advice straight away.

What the quality statement means for patients and carers

Children and young people under 16 who have had a urinary tract infection, and/or their parents or carers, are given information about how to recognise if they have another infection and to seek medical advice straight away.

Source guidance

NICE clinical guideline 54, recommendation 1.6.1.2.

Definitions of terms used in this quality statement

The healthcare practitioner (for example, a GP or hospital paediatrician) should give children and young people who have had a confirmed urinary tract infection, and/or their parents or carers, information and advice about possible re-infection and the importance of seeking medical advice straight away if there are signs of another urinary tract infection.

Equality and diversity considerations

Treatment and care, and the information given about it, should be culturally appropriate. It should also be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English.
Children and young people with a suspected or confirmed urinary tract infection, or their parents or carers, should have access to an interpreter or advocate if needed.

Laboratory reporting – differentiation of E. coli and non-E. coli organisms

This quality statement is taken from the urinary tract infection in infants, children and young people under 16 quality standard. The quality standard defines clinical best practice for urinary tract infection in infants, children and young people under 16 and should be read in full.

Quality statement

Infants, children and young people with a urinary tract infection caused by coliform bacteria have results of microbiology laboratory testing differentiated by Escherichia coli (E. coli) or non-E. coli organisms.

Rationale

Most urine infections are caused by E. coli bacteria, which belong to a group of bacteria called coliforms.
If a urinary tract infection is caused by a non-E. coli coliform or any other type of bacteria, there is an increased risk of serious underlying pathology. NICE guidance recommends that infants, children and young people (under 16 years) with atypical urinary tract infection (which includes infection with non-E. coli organisms) should have ultrasound of the urinary tract during the acute infection. It is therefore important that laboratory test reports differentiate between E. coli and non-E. coli organisms to identify whether further investigations are needed.

Quality measures

Structure
Evidence of local arrangements to ensure that microbiology laboratories detecting coliform bacteria as a cause of a urinary tract infection report results differentiated by E. coli or non-E. coli organisms.
Data source: Local data collection.
Process
Proportion of infants, children and young people with a urinary tract infection caused by coliform bacteria who have results of microbiology laboratory testing differentiated by E. coli or non-E. coli organisms.
Numerator: the number of people in the denominator who have results of microbiology laboratory testing differentiated by E. coli or non-E. coli organisms.
Denominator: the number of infants, children and young people (under 16 years) with a urinary tract infection caused by coliform bacteria.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers ensure that systems are in place for infants, children and young people with a urinary tract infection caused by coliform bacteria to have results of microbiology laboratory testing differentiated by E. coli or non-E. coli organisms.
Healthcare practitioners ensure that infants, children and young people with a urinary tract infection caused by coliform bacteria have results of microbiology laboratory testing differentiated by E. coli or non-E. coli organisms.
Commissioners ensure that they commission services for infants, children and young people with a urinary tract infection caused by coliform bacteria that report results of microbiology laboratory testing differentiated by E. coli or non-E. coli organisms.

What the quality statement means for patients and carers

Infants, children and young people under 16 with a urinary tract infection caused by coliform bacteria (a type of bacteria that usually live in the digestive system) have laboratory test results that show whether these bacteria were E. coli or not, to identify whether further investigations are needed.

Source guidance

Derived from definitions of atypical urinary tract infection as outlined in NICE clinical guideline 54.

Definitions of terms used in this quality statement

NICE clinical guideline 54 specifies atypical causes of urinary tract infection, and includes non-E. coli organisms as an atypical cause in infants, children and young people.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Commissioning

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Education and learning

NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Service improvement and audit

These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.

Pathway information

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on urinary tract infection in children.
NICE has also written a document for patients and the public explaining its quality standard for urinary tract infection in infants, children and young people under 16.

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Updates to this pathway

21 February 2014 Minor maintenance update
16 July 2013 Urinary tract infection in infants, children and young people under 16 quality standard added to the pathway, and minor maintenance updates.
5 June 2013 Update to change clinical guideline 47 links to Feverish illness in children pathway.
26 February 2013 Minor maintenance updates.

Supporting information

Glossary

Seriously ill (for more information refer to the NICE pathway on 'Feverish illness in children')
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.
Two or more episodes of UTI with acute pyelonephritis/upper urinary tract infection, or
One episode of UTI with acute pyelonephritis/upper urinary tract infection plus one or more episode of UTI with cystitis/lower urinary tract infection, or
Three or more episodes of UTI with cystitis/lower urinary tract infection.
Dimercaptosuccinic acid (DMSA) scintigraphy scan
Micturating cystourethrogram
Urinary tract infection
Vesicoureteric reflux

Paths in this pathway

Pathway created: August 2012 Last updated: February 2014

© NICE 2014

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