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Urinary tract infection in under 16s

About

What is covered

This interactive flowchart covers diagnosing, treating and managing urinary tract infections in under 16s.

Updates

Updates to this interactive flowchart

26 September 2017 Recommendations on urine testing strategies amended in line with the update of NICE guideline CG54 on urinary tract infection in under 16s.
10 February 2016 Restructured, and summarised recommendations replaced with full recommendations.
16 July 2013 Urinary tract infection in children and young people (NICE quality standard 36) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on diagnosing, treating and managing urinary tract infections in under 16s in an interactive flowchart

What is covered

This interactive flowchart covers diagnosing, treating and managing urinary tract infections in under 16s.

Updates

Updates to this interactive flowchart

26 September 2017 Recommendations on urine testing strategies amended in line with the update of NICE guideline CG54 on urinary tract infection in under 16s.
10 February 2016 Restructured, and summarised recommendations replaced with full recommendations.
16 July 2013 Urinary tract infection in children and young people (NICE quality standard 36) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.

Quality standards

Urinary tract infection in children and young people

These quality statements are taken from the urinary tract infection in children and young people quality standard. The quality standard defines clinical best practice for urinary tract infection in 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 children and young people quality standard. The quality standard defines clinical best practice for urinary tract infection in children and young people 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

Urinary tract infection in under 16s: diagnosis and management (NICE clinical guideline 54), recommendations 1.1.1.1, 1.1.5.2, 1.1.5.3, 1.1.5.4 and 1.1.5.5

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.
The NICE guideline on urinary tract infection in under 16s recommends urine-testing strategies according to 3 separate age groups. The urine-testing strategies are grouped as follows:
  • infants younger than 3 months
  • infants and children 3 months or older but younger than 3 years
  • children 3 years or older.
Assess the risk of serious illness in line with the NICE guideline on fever in under 5s 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 children and young people quality standard. The quality standard defines clinical best practice for urinary tract infection in children and young people 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

Urinary tract infection in under 16s: diagnosis and management (NICE clinical guideline 54), recommendation 1.1.7.1 (key priority for implementation)

Definitions of terms used in this quality statement

The NICE guideline on urinary tract infection in under 16s 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 children and young people quality standard. The quality standard defines clinical best practice for urinary tract infection in children and young people 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

Urinary tract infection in under 16s: diagnosis and management (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 children and young people quality standard. The quality standard defines clinical best practice for urinary tract infection in children and young people 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 the NICE guideline on urinary tract infection in under 16s: diagnosis and management.

Definitions of terms used in this quality statement

The NICE guideline on urinary tract infection in under 16s specifies atypical causes of urinary tract infection, and includes non-E. coli organisms as an atypical cause in infants, children and young people.

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Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Glossary

Includes seriously ill (for more information refer to NICE's recommendations 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.
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 1 or more episode of UTI with cystitis/lower urinary tract infection, or 3 or more episodes of UTI with cystitis/lower urinary tract infection.
bacteria in the urine with or without urinary tract infection
dimercaptosuccinic acid
micturating cystourethrogram
white cells in the urine
suprapubic aspiration
urinary tract infection
vesicoureteric reflux

Paths in this pathway

Pathway created: August 2012 Last updated: September 2017

© NICE 2017. All rights reserved. Subject to Notice of rights.

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