Paediatric Pathways

Pyelonephritis (PN) / upper UTI pathway for children presenting to hospital

DIAGNOSIS

It can be difficult to differentiate upper from lower UTI especially in younger children.
However features suggestive of PN include fever, malaise, vomiting, poor feeding, irritability, loin pain and renal tenderness.1

Consider differentials:

  1. Lower UTI - dysuria, frequency, urgency and incontinence with a low grade or absent fever
  2. Vulvitis/balanitis, dehydration - dysuria without fever
  3. Other sepsis
  4. Type 1 diabetes - urinary frequency

INVESTIGATIONS

Urine dipstick and culture:
i) For infants and children who are not toilet trained: urine samples should ideally be obtained by in out catheterisation or SPA (data suggest 26% of clean catch urine specimens are contaminated*)2
DO NOT send bag urines or urine from pads for culture due to even higher risk of contamination.2*
ii) For toilet trained children send correctly performed midstream clean catch urine sample. Provide clear instructions to parents/carers.

Other investigations include U&E, renal function, CRP and blood culture.3 Empirical lumbar puncture (LP) if <28 days with presumed PN/upper UTI**4-6 or clinical concerns for bacterial meningitis – check for contraindications to LP

  • Check blood pressure.

Arrange urgent inpatient renal tract USS if severe infection/sepsis, poor urine flow, abdominal or bladder mass, raised creatinine, failure to respond to treatment with suitable antibiotics within 48 hours, or infection with non-E. coli organisms.7

MANAGEMENT

Empiric antimicrobial therapy should be initiated immediately after appropriate urine collection (do not delay IV antibiotics if sepsis suspected7)

Initial enteral treatment if:8

  • >3 months old AND clinically stable and not septic
  • able to tolerate and absorb enteral antibiotics

Evidence suggests enteral therapy as effective as initial IV therapy followed by oral switch9

Choice of oral Abx as per local/national guidelines
Consider risk factors for aminoglycoside toxicity ***
Total duration of antibiotics 7 days7,8
Choice of Abx as per local/national guidelines7
Provide verbal and written safety netting information

MANAGEMENT

Initial IV therapy if:7,8

  • sepsis
  • <3 months old (pending blood ± CSF culture results)
  • ill appearance
  • unable to tolerate or absorb enteral antibiotics

Consider initial IV therapy if:

  • costovertebral angle tenderness
  • Significant immunosuppression
  • known urologic abnormality

Consider ambulation9 on IVAbx from ED / assessment unit (admission avoidance) unless:

Ensure robust clinical governance systems and documentation in place for children being ambulated
Daily review required and provide verbal and written safety netting information
IV to oral switch (pending blood and urine cultures) when:

  • Clinically improving +- improving inflammatory markers
  • Apyrexial
  • Choice of oral Abx as per local/national guidelines. Total duration of treatment (IV+oral) = 7 days (10 days if bacteraemia)

Arrange outpatient follow-up and investigations as per national guidelines.

If clinically deteriorating or remains pyrexial despite antibiotics, consider:

  • Deep seated infection requiring source control: consider imaging (USS)
  • Resistant organism – check risk factors and microbiology results
  • Non-infective pathology or unusual infection (consider differentials)
  • Seek ID/micro advice if complex infection

* Urine sample contamination rates in children <2 years2:

SPA - suprapubic aspiration - 1%
In out catheter - 12%
Clean catch urine - 26%

** Concomitant UTI and meningitis is uncommon in infants and children over 4 weeks of age.3

Bacteraemia in UTI is inversely related to age with most cases under 6 months.4 5

*** Conditions that predispose to aminoglycoside toxicity (BNFc)

  1. chronic renal failure or deteriorating renal function
  2. chronic liver disease
  3. severe cholestasis
  4. significant conductive hearing problems
  5. vestibular symptoms

The development of this pathway involved a systematic review of the literature, collaborative development of the pathway with relevant national groups followed by formal national consultation. For more information, click here

REFERENCES
  1. Lambert H, Coulthard M. The Child with urinary tract infection. In: Webb N and Postlethwaite R, editors. Clinical Paediatric Nephrology. 3rd ed. Oxford University Press; 2003.p.197-227.
  2. Tosif S, Baker A, Oakley E et al. Contamination rates of different urine collection methods for the diagnosis of urinary tract infections in young children: an observational cohort study. J Paediatr Child Health 2012; 48: 659-64.
  3. Pitetti RD, Choi S. Utility of blood cultures in febrile children with UTI. Am J Emerg Med 2002; 20: 271-4.
  4. Tebruegge M, Pantazidou A, Clifford V et al. The age-related risk of co-existing meningitis in children with urinary tract infection. PLoS One 2011; 6: e26576.
  5. Bachur R, Caputo GL. Bacteremia and meningitis among infants with urinary tract infections. Pediatr Emerg Care 1995; 11: 280-4.
  6. Nugent J, Childers M, Singh-Miller N et al. Risk of Meningitis in Infants Aged 29 to 90 Days with Urinary Tract Infection: A Systematic Review and Meta-Analysis. J Pediatr 2019; 212: 102-10 e5.
  7. NICE (National Institute of Health and Clinical Excellence). Urinary tract infection in under 16s: diagnosis and management. Clinical Guideline [CG54]. Available at https://www.nice.org.uk/guidance/cg54. 2007.
  8. Strohmeier Y, Hodson EM, Willis NS et al. Antibiotics for acute pyelonephritis in children. Cochrane Database Syst Rev 2014; https://dx.doi.org/10.1002/14651858.CD003772.pub4: CD003772.
  9. Patel S, Abrahamson E, Goldring S et al. Good practice recommendations for paediatric outpatient parenteral antibiotic therapy (p-OPAT) in the UK: a consensus statement. J Antimicrob Chemother 2015; 70: 360-73.