What is a urinary tract infection (UTI)?
A urinary tract infection is a common bacterial infection of the urinary system in infants and small children. It is often difficult to recognize a urinary tract infection in children, because the symptoms and the clinical picture are non-specific, particularly in children under 3 years old.
What are the symptoms of a urinary tract infection?
It usually presents in small children with a persistent fever above 38C, and lasts for more than 24 hours. Following on from that:
• When a child has a low-grade fever that passes after 24 hours, a urine test is NOT required, in order to exclude a urinary tract infection.
• Small children catch many viruses and simple illnesses with a fever, up to 10-15 times a year. Not all of these episodes require testing for a urinary tract infection, because a common way of obtaining a sample (with a small bag) frequently leads to false-positive results, to over-diagnosis of urinary tract infections, and to unnecessary examinations, treatment, and suffering for parents and children.
In most cases of simple viruses, the doctor evaluates information from the child’s medical history, in order to find the origin of the viral infection and the fever. For instance, it helps to diagnose the illness when there is not just a fever, but when:
- It is accompanied by symptoms of the upper respiratory system, such as a runny nose, coughing, sore throat
- The fever is mild, and the child seems to be doing well
- The fever does not persist for a second day
- Other members of the family or contacts at the nursery school have had a viral illness or a cold in the last few days.
In addition to this, the reason for the infection, e.g. redness of the ear or pharynx, or signs in the chest etc., is frequently discovered during the clinical examination of the child. Therefore, an informed clinical physician attempts to assess the possibility of a severe infection, such as a urinary tract infection, but at the same time, tries to reassure parents concerning the overwhelming majority of febrile episodes in children, and not to create unnecessary stress. Sometimes, an inexplicably high fever for more than one day justifies testing of the child’s urine in the appropriate way.
What other symptoms can indicate a urinary tract infection in a child?
Older children may have symptoms of common cystitis (pain during urination and a burning sensation, interrupted and slow urine flow, frequent urination, cloudy urine, without significant fever).
Pyelonephritis is a bacterial infection of the upper urinary system (kidneys), and has more severe symptoms (e.g. high fever, shivering, pain in the back, fatigue, weakness, and poor appetite). Young children with a high fever, and who seem restless, should be referred to the hospital, in order to exclude serious infections (e.g. pyelonephritis, meningitis).
Other symptoms may include irritability, abdominal pain, lack of appetite and poor nutrition, vomiting, prolonged infantile jaundice, peculiar smelling of urine and cloudy urine, haematuria (blood in the urine).
How is the diagnosis of a urinary tract infection made?
When a urine test is prescribed for an infant or a child, the recommended method is a “clean catch urine sample.” That is, the parent offers fluids to the child, or the mother breastfeeds the infant, opens the nappy, and washes the area with soap and water, wipes it dry, and then leaves the nappy open, and with the infant in his/her arms, or asleep, waits until he urinates. As soon as the child urinates, and with the sterile container close by, he/she opens it, and collects the urine.
The collection of urine with a bag IS NOT the recommended collection method in most cases, because the sample often contains bacteria from the neighboring skin. An alternative method is recommended in some cases, for example, when the child’s symptoms are not urgent, and a clean catch sample cannot be taken after much effort. In these cases of non-invasive collection with a bag, it is important to explain to the parents the instructions for use and its proper application.
If, due to the severity of the child’s symptoms, it is urgently necessary to collect a urine sample, or if it is not practical to collect urine with non-invasive methods, then the exclusion of a urinary tract infection should be made with direct collection of urine from the bladder, either with a suprapubic aspiration (a tube inserted into the bladder through the abdomen) for infants, or with an urethral catheter for infants and small children. In the case of a suprapubic tap, an ultrasound scan MUST be done simultaneously, in order to ensure the presence of urine in the bladder and proper guidance.
How is the diagnosis of urinary tract infection made definitely?
Urinalysis (testing of the urine) indicates evidence of a urinary tract infection (presence of pus white cells, red blood cells, proteins, nitrates).
The selected definitive method for the diagnosis of a urinary tract infection is a urine culture.
A culture from a non-invasive method (clean catch or bag) is considered to be:
1. Positive, if a single colony of bacteria (e.g. E-coli, klebsiella or proteus) > 100,000 per ml is found.
2. Negative, if no colony is found, and
3. Non-conclusive, and needs to be repeated, if the result reveals a mixed growth of many different bacteria, or bacteria in a concentration of < 100,000 per ml.
In any case, the doctor takes the results of the test into consideration, together with the history of symptoms, clinical image, urinalysis, and the risk factors for the child.
To clarify, an illness accompanied by a fever cannot be considered to be a urinary tract infection simply from the findings of urinalysis, or from samples with mixed growth, or samples with growth of 10,000 or 1,000 microbes per ml.
Urine culture by an invasive method is considered to be positive, when
the result is growth of even a small number of a colony of bacteria, assuming that the collection was done in a proper and sterile way.
On the other hand, if a child has severe symptoms that indicate a urinary tract infection, then antibiotics should be administered, ideally after two urine samples have been collected for examination, and then antibiotics are stopped or continued according to the final results of the tests.
Are there children with risk factors for urinary tract infections?
There are. In these cases, the doctor should remain alert, and request testing for a urinary tract infection with the presence of relatively mild symptoms:
• Children with a history of previous urinary tract infections
• Children with a history of persistent febrile conditions that indicates unverified urinary tract infections in the past
• Children with low urine flow
• Children with documented anomaly of the urinary system before birth during an ultrasound (e.g. hydronephrosis)
• Children with a family history of renal diseases or vesicoureteral reflux (the abnormal flow of urine from the bladder to the upper urinary tract)
• Children with a persistent history of constipation
• Children with a distended bladder
• Children with a palpable mass in the abdomen
• Children with stagnation in physical growth
• Children with high blood pressure
Which children with a possible urinary tract infection need hospitalisation?
Infants under 3 months old with an persistent fever over 38C should be referred to the hospital, in order to exclude a urinary tract infection, and be provided with further care. Children with severe symptoms and persistent high fever may also need to be referred to the hospital.
How is a urinary tract infection treated? Which antibiotics should be given?
Before the results of urine culture test come out, antibiotics of a spectrum as narrow as possible, and of the minimum possible appearance of bacterial resistance should be administered. These usually include amoxicillin, co-amoxiclav, and cephalosporins.
With the result of the urinalysis and the sensitivity test for antibiotics, the most effective antibiotic against the specific bacteria is determined.
In severe cases, such as pyelonephritis, cases in young infants, or when antibiotics cannot be administered orally, cefotaxime or ceftriaxone are administered intravenously for 2 to 4 days, and for at least 24 hours after the recession of the symptoms and fever. After that, antibiotics are administered by mouth for a total duration of treatment of 10 days. Longer duration of treatment than these recommendations in a child with decreasing symptoms, (e.g. intravenous antibiotics for a week and/or antibiotics by mouth for 2 or 3 weeks) are not scientifically supported, constitute overtreatment, and carry the risks of antibiotics misuse (destruction of healthy bacterial flora, resistance to antibiotics, diarrhea, undue suffering for parents and children etc).
In mild episodes of urinary tract infection, e.g. cystitis without fever in children older than 3 months, the recommended duration of treatment with antibiotics is 3 days. Alternative antibiotics include amoxicillin, cephalosporin, nitrofurantoin, or trimethoprim. In these cases also, treatments with stronger antibiotics, or for longer than 3 days, are not justified by scientific data, constitute overtreatment, and carry the risks of antibiotics misuse (destruction of healthy bacterial flora, resistance to antibiotics, diarrhea, undue suffering for parents and children etc).
Whatever the circumstances, before antibiotics are administered, it is necessary to send at least one urine sample for urinalysis, urine culture, and detection of sensitivity, in order to determine the correct choice of antibiotics.
Furthermore, if, despite the administration of antibiotics, the infant or child does not improve within 24 to 48 hours, parents should be advised to take the child back to the doctor for re-evaluation.
In all cases, care focused on the child is required. Health professionals should take into account the individual needs and preferences of children and their parents for treatment. Good communication with the parents and child is necessary, supported by information based on scientific documentation, which will allow parents to make actual informed decisions, in relation to the care of their child.
What other examinations are necessary for a child with a urinary tract infection?
A complete radiological assessment of the urinary system should be done in many cases, in order to exclude anomalies that increase the possibility of urinary tract infections.
Specifically, an ultrasound of the urinary system should be done for infants under 6 months old. In infants with repeated urinary tract infections (2 or more), or with one urinary tract infection with non-typical or severe symptoms, a cystourethrogram (a test done to examine the bladder and urethra while the bladder fills and empties), and a DMSA scintigraphy (scan) should be done. Therefore, it is not necessary for all infants with a typical urinary tract infection to undergo a cystourethrogram and a DMSA scintigraphy scan.
For children between 6 months and 3 years old, with a single episode of a typical urinary tract infection, and who responded to treatment within 48 hours, no further testing is required. It is recommended that infants of this age with non typical urinary tract infections, or with two episodes or more, should undergo renal ultrasound and DMSA scintigraphy scanning, while carrying out a cystourethrogram is individualized according to risk factors.
Children older than 3 years, with a urinary tract infection, should do further tests, only if there are repeated cases (renal ultrasound and DMSA scan).
Should children with urinary tract infections take preventive measures with antibiotics?
The administration of antibiotics as a prevention, after one urinary tract infection, aiming to prevent future urinary tract infections, should NOT be recommended as routine in infants and children.
The administration of antibiotics as a precaution is a choice that should be taken into consideration, in cases of repeated or recurrent urine tract infections or anomalies of the urinary tract.
Should children with a history of urinary tract infections periodically have their urine tested as a precaution?
No. Urine testing “as a precaution” for urinalysis and culture, once a month or at other intervals, for a clinically healthy infant or child, and particularly when samples are collected with a bag, has no scientific basis, may cause unnecessary stress, and lead to over-diagnosis and over-therapy of the child. If a child has no symptoms, but the result of urine culture is bacteriuria – presence of bacteria –, there is no scientific evidence for the administration of antibiotics, and they should not be administered.
Infants and children, who remain asymptomatic after a single episode of a urinary tract infection, should NOT have their urine routinely tested regularly for re-examination for a urinary tract infection.
Parents should be instructed to notify the doctor whenever their child has symptoms that may suggest a urinary tract infection, and to be mindful of re-examination and clinical examination by their doctor, in cases of persistent febrile illnesses.
Are there other measures for the prevention of urinary tract infections in children?
Encourage intake of lots of fluids.
Treat constipation, and the dysfunction of the bladder, on time, and adequately.
Train the child not to delay urination, not to hold his urine for a long time, and to empty his bladder the best he can.
Encourage wiping from the genitals towards the anus, and not vice-versa.
Source: NICE guidelines http://publications.nice.org.uk/urinary-tract-infection-in-children-cg54
Translation/Comments: Stelios Papaventsis MRCPCH DCH IBCLC 2012