Consensus Guidelines for Management of Pediatric Urinary Tract Infection (UTI)

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Northern California Pediatric Hospital Medicine Consortium

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Table of Contents

• Executive Summary
• Introduction
• Criteria for Use of Guideline
• Definitions
• Evaluation
• H&P
• How to Test
• Urinalysis (UA) Interpretation
• Urine Culture Interpretation
• Additional Laboratory Studies
• Imaging
• Other Health Screening
• Management
• Who Should Receive Empiric Antibiotics?
• Table 1: Empiric Treatment
• Admission Criteria
• Refractory UTI
• Treatment Duration
• Subspecialty Consultation
• Discharge Criteria
• References
• APPENDIX I: Clinical Pathway for Evaluation of Urinary Tract Infections in Children
• APPENDIX II: History and Physical Resource

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Executive summary

Objectives

1. To define the clinical circumstances under which testing for UTI is indicated and reduce unnecessary testing for UTI.
2. To ensure the method of testing for UTI is appropriate based on age and probability of UTI.
3. To elucidate the appropriate laboratory studies and imaging for children with UTI and reduce the use of high-radiation studies.
4. To recommend appropriate empiric antibiotic therapy in children with suspected or confirmed UTI.
5. To define admission criteria for children with UTI.
6. To suggest appropriate subspecialty consultation in non-typical clinical circumstances.

Recommendations

How to Test

• Choice of collection method should consider the prior probability of UTI, the age of the child, parental preference, and the implications of a false positive or false negative result. The UCSF PHM consortium strongly recommends that bag specimens not be sent for culture, but in the circumstance of parental declination or inability to obtain a catheter specimen, this method should be documented, and stringent interpretation criteria should be applied when the culture result returns.
• When to Send a Culture
  • Urine cultures should be sent for all children < 6 months suspected of UTI regardless of UA results, when collecting catheterized urine sample
  • Urine cultures should be sent for all children with urinary symptoms and a positive UA (+LE and/or +nitrites), and all who are started on empiric antibiotics for suspected UTI.

Labs

• Blood culture and LP may be indicated based on age and clinical appearance of patient. Other labs are not routinely recommended. 

Imaging/Testing

• RBUS (ultrasound of kidneys and bladder) is indicated for first time febrile UTI in patients <24 months. Other imaging not routinely recommended.
• Toilet-trained children with UTI should be screened for bladder and bowel dysfunction.

Treatment

• Empiric antibiotic guidelines and recommendations on duration of therapy can be found here: https://idmp.ucsf.edu/content/urinary-tract-infections-community-onset

Methods

This guideline was developed through local consensus based on published evidence and expert opinion as part of the UCSF Northern California Pediatric Hospital Medicine Consortium.

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Introduction

Criteria for Use of Guideline:

• Inclusion/Exclusion Criteria: This guideline is designed for use in all children under age 12 with suspicion for or known community-acquired UTI, except for those children who have kidney transplants, indwelling urinary catheters or urinary tract instrumentation, or profoundly immunocompromised status.

Children in Whom There May be Concern for UTI

• Fever without a source in select infants
  • Infants < 3 months of age: Fever (T greater than or equal to 38) without source
  • Infants/Toddlers greater than or equal to 3 months of age: Fever of greater than or equal to 39 for > 24 hrs without a source in uncircumcised boys and girls < 2 years of age
• Historical risk factors (to be considered along with clinical risk symptoms)
  • Known history of vesicoureteral reflux or other urogenital malformations
  • Previous UTIs (UTI history should be carefully confirmed)
  • Recent bladder catheterization
  • Bladder and bowel dysfunction, preschool and older, peaks in school age children

UTI Calculator

• UTI probability calculator based on clinical characteristics developed by the University of Pittsburgh, applies to children aged 2-23 months:

https://uticalc.pitt.edu/

Common Uropathogens (include in empiric coverage):

• Enteric gram-negative rods (i.e. coli, Klebsiella spp., Proteus spp.)

Less common uropathogens (NOT routinely included in empiric coverage):

• Enteric gram-negative rods with potential antibiotic resistance
  • ESBL-producing organisms (e.g. fraction of coli, Klebsiella spp.)
  • Organisms with potential ampC-production (e.g. Enterobacter spp, Citrobacter spp)
• Pseudomonas aeruginosa: increased concern in patients with hospital-acquired UTI, indwelling catheters, significant prior antibiotic exposure
• Enterococcus spp*
• Candida spp*

*These organisms are more likely to represent colonization or contamination when isolated from urine cultures.  Correlate with clinical picture, consider confirmatory culture.

Definitions

UTI: A combination of clinical symptoms, pyuria, and positive urine culture at quantities below:

For cultures collected by catheterization in young children, greater than or equal to 50,000 CFU/ml, with the caveat that some laboratories may not report quantities in between 10,000-100,000 CFU/ml. Additionally, in infants and toddlers who have high pretest probability for UTI, with otherwise compatible symptoms and urinalysis results, greater than or equal to 10,000 CFU/ml of a typical uropathogen (E. coli) could be consistent with a true UTI.

For cultures collected by clean catch in older children, cutoffs of greater than or equal to 100,000 CFU/ml are recommended.

Pyelonephritis: A UTI with bacterial infection of the kidneys.  Involvement of the kidneys in this guideline does NOT automatically constitute a complicated or atypical UTI.  This is different from terminology commonly used in adult medicine and reflects the commonality of upper urinary tract involvement in otherwise healthy young children with UTI.

Atypical pathogens: Infection with organism other than E. coli, Proteus spp, or Klebsiella spp

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Evaluation

H&P

Detailed history and physical exam assessing acute signs/symptoms as well as any history of contributing factors. (See Appendix II for a suggested checklist of items for assessment)

Who to Test (See Appendix I)

Infants/children < 2 years of age (presenting with fever without a source): 

• For infants < 3 months of age with fever > 38 without apparent source: catheter collection for UA and urine culture
• For infants > 3mo-2 years of age presenting with fever> 24 hours: use UTI Calculator to determine probability of UTI

 Children > 2 years of age without known risk factors of UTI:

• Presenting with focal symptoms of UTI (dysuria, urinary frequency, hematuria, abdominal pain, back pain or new daytime incontinence) and without viral symptoms (e.g. cough, diarrhea, rash): use UTI Calculator to determine probability

Children with KNOWN RISK FACTORS for UTI (including but not limited to multiple previous UTIs, known GU anomaly, high-grade VUR, recent catheterization, frequent or recent GU instrumentation)

• Presenting with fever without a source OR focal symptoms of UTI (dysuria, urinary frequency, hematuria, abdominal pain, back pain or new daytime incontinence) and without viral symptoms (e.g. cough, diarrhea, rash): recommend testing urine for UTI

How To Test

Collection Method (see Appendix I)

• Choice of collection method should consider the prior probability of UTI, the age of the child, parental preference informed by dialogue with clinicians, and the implications of a false positive or false negative result.
• In general:
  • Infants < 3 months of age should have urine collected by catheter
  • For children >3 months of age who are toilet trained or can urinate into a cup (e.g. induced urination⁴, opportunistic collection), obtain urine via clean catch for UA and culture if positive.
    • Parental supervision of pre-test cleansing and midstream clean-catch should be done to reduce contamination in children <6 years of age or older if developmentally appropriate.
  • For children >3 months of age in whom clean catch is UNABLE to be obtained, there are three possible options:
  1. catheterized collection for all children who are not toilet-trained
  2. 2-step screen with bag UA -> if UA positive, obtain cath urine for culture
  3. clean catch opportunistic or induced⁴
• There is a role for shared decision making with parents in determining how to test for UTI. We recommend using the UTI calculator as a tool in shared decision making with parents of children 2-23 months. Some parents may prefer to test earlier at the time of initial presentation, even if fever has been less than 24-48 hours, to prevent a return visit, whereas others may want to limit intervention. Similarly, some parents may prefer a definitive result with a catheter urine specimen for UA and urine culture, whereas some parents may refuse or strongly object to catheterization for any specimen.

• The UCSF PHM consortium strongly recommends that bag specimens NOT be sent for culture, but in the circumstance of parental declination or inability to obtain a catheterized specimen, this method should be documented and stringent interpretation criteria should be applied when the culture result returns. Additionally, only positive bag UA specimens should be sent for culture.
• A negative urinalysis (UA) from a bag specimen has a similar negative predictive value to catheter specimen in average risk patients.
• Always document the method of collection (catheter, bag, clean catch).
• A clean catch can be obtained in multiple ways, but generally refers to a midstream urine from a cleansed perineum into a sterile container.
• While this guideline does not apply to patients with known immunocompromise including neutropenia, it is important to avoid catheterizing patients who are known or suspected to be severely neutropenic.

Urinalysis (UA) Interpretation

• Positive leukocyte esterase: very sensitive, but less specific for true infection (false positives are common)
  • Note: if no WBC on microscopy, more likely to be a false positive
  • Higher range of leukocyte esterase (2-3+) supports UTI more than lower range (trace-1+)
• Positive nitrite: high specificity for UTI, but lower sensitivity
  • e. positive nitrite means likely UTI, but negative nitrite does not rule out UTI
  • Can also see positive nitrite in contaminated specimen if left at room temperature for too long
• Positive blood and protein: not specific for UTI
        Microscopy: Laboratories report results on different scales that are not equivalent
• Pyuria is defined as >10 WBC/mm³ or >5 WBC/HPF
• Similar to leukocyte esterase, higher levels of pyuria by microscopy are associated with higher likelihood of UTI.
• Refer to UTI Calculator with urinalysis results to update probability of UTI in younger children 2-23 months. For older children, the UA should be interpreted according to your assessment of pre-test probability, and the result values:
  • Positive nitrite increases likelihood of UTI substantially
  • Higher levels of positive leukocyte esterase (e.g. 3+) or WBC increase the likelihood of UTI to a greater degree than lower levels.
  • Low levels of leukocyte esterase / WBC (e.g. trace, 1+) with negative nitrite do not greatly increase the likelihood of UTI.

When to send a culture:

• Urine cultures should be sent for all children <3 months suspected of UTI regardless of UA results if cath specimen obtained, to avoid needing to repeat catheterization.
• Urine cultures should be sent for all children < 12-year-old with urinary symptoms and a positive UA (+LE and/or +nitrites), and all who are starting antibiotics empirically for UTI.

Urine Culture Interpretation

• Results suggestive of true infection (not contamination or colonization):
  • +UA and >50,000 cfu/mL of a single uropathogen from a catheterized specimen (2011 AAP UTI Guidelines), greater than or equal to 10,000 CFU/ml may also be consistent in <2 year old age group if it is a typical uropathogen (E coli)
  • >100,000 CFU/ml of a single uropathogen from a clean catch specimen.
  • Note: if bag specimen sent for culture because of parental declination or inability to obtain catheter specimen, a higher threshold, such as >100,000 cfu/mL, should be used
• Presence of >1 organism or mixed urogenital flora are usually consistent with contamination. If there is strong clinical suspicion, repeat urine collection should be considered.

Additional Laboratory Studies

• Blood culture: recommended for febrile infants < 3 months of age or toxic-appearing child of any age per guidelines for fever without a source in infants
• LP: recommended for all febrile neonates (see Febrile Infant Guideline for more detail) https://medconnection.ucsfbenioffchildrens.org/febrile-infant-guidelines
• Test of cure after treatment: NOT routinely recommended
• Metabolic panel/electrolytes/lactate: NOT routinely recommended
• CBC and CRP: NOT routinely recommended

Imaging

• Renal (and Bladder) Ultrasound
  • Recommended during acute illness if clinical course is severe, and/or patient not responding to treatment as expected (e.g. within 48 hours of starting treatment) to diagnose complications (renal abscess, stone, etc)
    • Note: Renal ultrasound during acute infection can be misleading in diagnosis of urinary tract abnormalities: coli endotoxin can produce dilation, which might be confused with hydronephrosis or obstruction; and edema can cause changes in the size and shape of the kidneys, along with the echogenicity of renal parenchyma.
  • Recommended for all children <2 years of age with first time febrile UTI
    • Timing depends on the clinical situation: for those who respond well to therapy, and who have reliable outpatient follow up, renal ultrasound can be deferred to after acute infection has resolved (4-6 weeks). Ability to obtain a quality study and ability for patients to follow up should be considered.
    • Other guidelines (such as NICE) recommend US for children <6 months, our guidelines align with the most current AAP recommendations

• VCUG
  • NOT routinely recommended after first febrile UTI
    • Indicated if renal ultrasound shows severe hydronephrosis, bladder hypertrophy or other findings suggestive of high grade VUR or obstructive uropathy
  • Consider in infants (< 2 years of age) with recurrent febrile UTI AND abnormal ultrasound
• DMSA scan
  • NOT routinely recommended in the evaluation of UTI

Other Health Screening

• The most common reason for recurrent UTI in preschool and older children is voiding dysfunction
• For toilet trained children with UTI, screen for bladder and bowel dysfunction (BBD) using a validated screening instrument:
  • https://www.mountsinai.org/files/MSHealth/Assets/HS/Care/Urology/PediatricUrology/Peds-DVSS.pdf
  • or Vancouver Symptom Score
• Children who present with urinary symptoms, especially if recurrent or persistent, but do not have UTI based on UA and culture criteria, should also be evaluated for BBD.

A note on health equity and race-based medicine:

The following figure, entitled “Probability of UTI Among Febrile Infant Girls and Infant Boys According to Number of Findings Present,” is from the 2011 AAP Clinical Practice Guideline, Urinary Tract Infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months.

We do not agree with the use of race correction in clinical algorithms, such as those in the AAP 2011 UTI guidelines, which assign lower likelihood of UTIs in Black children. This systematically deters clinicians from pursuing definitively diagnostic testing for Black children presenting with symptoms of UTI and exacerbates treatment disparities. Thus, in this revision of our consortium guidelines, we have removed race-based criteria in the pursuit of more accurate and equitable care for all our patients. The AAP guideline has also been retired and is under revision to update to more appropriate risk classification. The UTI Calculator is an objective source of risk estimates for children <2 years old and has been modified to remove race.

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Management

Who Should Receive Empiric Antibiotics?

*Note: A “positive UA” for the purposes of these guidelines is defined as positive leukocyte esterase or nitrite.  As above, if microscopy is available, it should be used to guide decision-making.  UA findings should also be interpreted in the context of method of collection and the degree of abnormality.  Of note, a point of care (POC) UA is a reasonable alternative to lab UA, and shown to decrease ED stay time.

• Empiric antibiotics should be given to:
  • Child <3 months of age with positive UA
  • Child 3 months – 1 year of age who is FEBRILE with a positive UA
  • Any child with a positive UA who is ILL/TOXIC-APPEARING
• In a child 3 months to 12 years of age who is AFEBRILE and WELL-APPEARING, it is reasonable to consider deferring empiric treatment if UA is mildly positive or equivocal (e.g.: trace-1+LE, negative nitrite,) while awaiting culture results. Conversely, if the history is very consistent with UTI and positive UA, start treatment empirically. For children <2, it is recommended to use the UTI calculator to stratify likelihood.

 

Table 1: Empiric Treatment

Source: Benioff Children’s Hospital – San Francisco Antimicrobial Stewardship Program: 2021 Empiric Antimicrobial Therapy Guidelines, visit: idmp.ucsf.edu for the most updated version

• Note: Consider follow up after 48-72 hours to assess response to treatment. Routine laboratory follow-up is recommended: If urine culture is negative, has mixed flora only, or otherwise does not meet UTI diagnostic criteria, inform the family to update the diagnosis and stop antibiotic treatment.

 

Admission Criteria

• Clinically ill-appearing/toxic-appearance
• Severe dehydration/inability to tolerate PO liquids, requiring IV fluids
• Neonates (age <28 days of age) with fever
• Infants aged 29-60 days of age with fever & positive UA
  • In most cases these patients should be admitted
  • In the case of a child who is very well-appearing and well-hydrated with good guaranteed follow up within 24 hours and reliable caregivers and no other high risk lab abnormalities, it is not unreasonable to discharge following a dose of IV/IM antibiotics with a prescription for oral antibiotics
  • All patients in this age group should have a blood culture prior to discharge.

• Urine culture positive for multidrug resistant organism, without any good options for oral treatment
  • For ESBL-producing E coli or Klebsiella, the following antibiotics may be used if the organism is susceptible:
    • Trimethoprim-sulfamethoxazole (preferred)
    • Ciprofloxacin
    • Nitrofurantoin for cystitis only, not pyelonephritis or febrile UTI
• Unable to tolerate oral medications
  • If this is the only criteria for admission but the child is otherwise hydrating orally, consider other oral or IM options (e.g. flavoring medication, increased teaching, etc.)
• Patient’s family with unreliable access to outpatient care or follow up
• Failure to respond to outpatient therapy
  • Most patients will become afebrile and show clinical improvement after 48-72 hours of adequate antibiotic therapy
  • Note: The UTI diagnosis should be re-evaluated and confirmed with objective support if there is not a response. Other diagnoses (e.g. appendicitis) should be assessed.
• Positive blood culture
  • In many cases, routine UTI management may be appropriate, but not in all cases. Consult ID if there is clinical uncertainty.

Refractory UTI

Re-evaluate UTI diagnosis - does the patient objectively meet criteria? Evaluate other possible diagnoses.

If the patient remains febrile after 48-72 hours and/or is clinically worsening, consider suppurative complications as well as resistant or unusual organisms. Consider obtaining renal ultrasound.

If the patient is stable, review culture results and consult ID prior to broadening antibiotics.

Treatment Duration

• See Table 1 for full specific recommendations, but in general:
• Febrile Community-acquired UTI: 7 days for most patients, individualized per ID consult guidance for patients with significant complications?
• Community-acquired UTI without fever: 7 days

Subspecialty Consultation

• Pediatric Infectious Disease:
  • Consider for severe infection or concurrent bacteremia if there are questions about management
  • Consider if no response to treatment within 48 hours or fever >48-72 hours after starting treatment
  • If unusual organism or multi-drug resistance pattern
  • If the patient is immunosuppressed/immunocompromised or has other risk factors not covered in this guideline.
• Consider urology consultation for:
  • Urinary tract obstruction
  • Patient with known history of urologic abnormalities or recent instrumentation
  • Abnormal imaging
  • Recurrent UTI evaluation (voiding dysfunction, constipation, etc)

Discharge Criteria

• Clinically improving with improving fever curve
• Adequate PO liquid intake and tolerating oral antibiotic
• Aid in ensuring follow up

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References

1. AAP Clinical Practice Guideline. Urinary Tract Infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. 2011. Pediatrics. 128,3: 595-610.
2. Marmor A. Evidence-based review of diagnosis and management of urinary tract infection in febrile infants/children <24 months of age. UCSF Wiki. March 2012.
3. National Institute for Health and Clinical Excellence. Urinary tract infection in children: NICE guideline. June 2010. https://www.nice.org.uk/guidance/cg54
4. The QuickWee trial: protocol for a randomized controlled trial of gentle suprapubic cutaneous stimulation to hasten non-invasive urine collection from infants.Kaufman J, Fitzpatrick P, Tosif S, Hopper SM, Bryant PA, Donath SM, Babl FE. BMJ Open. 2016 Aug 10;6(8):e011357. doi: 10.1136/bmjopen-2016-011357.
5. Vyas DA, Eisenstein LG, Jones DS. Hidden in Plain Sight - Reconsidering the Use of Race Correction in Clinical Algorithms. N Engl J Med. 2020 Aug 27;383(9):874-882. doi: 10.1056/NEJMms2004740. Epub 2020 Jun 17. PMID: 32853499.
6. Tej K. Mattoo, Nader Shaikh, Caleb P. Nelson; Contemporary Management of Urinary Tract Infection in Children. Pediatrics February 2021; 147 (2): e2020012138. 10.1542/peds.2020-012138
7. Yang S, Gill PJ, Anwar MR, et al. Kidney Ultrasonography After First Febrile Urinary Tract Infection in Children: A Systematic Review and Meta-analysis. JAMA Pediatr. 2023;177(8):764–773. doi:10.1001/jamapediatrics.2023.1387
8. Robinson et al. Urinary tract infection in infants and children: Diagnosis and management. Canadian Paediatric Society Position Statement. Paediatr Child Health 2014;19(6):315-19
9. Melanie C. Marsh, Guillermo Yepes Junquera, Emily Stonebrook, John David Spencer, Joshua R. Watson; Urinary Tract Infections in Children. Pediatr Rev May 2024; 45 (5): 260–270. https://doi-org.ucsf.idm.oclc.org/10.1542/pir.2023-006017

 

Published Children’s Hospital Guidelines / Pathways

Children’s Hospital of Philadelphia (CHOP)

Cincinnati Children’s

Seattle Children’s

UCSF BCH San Francisco, Pediatric Antimicrobial Stewardship Program  BCH Community Acquired UTI Empiric Antibiotic Therapy Guidelines.  http://idmp.ucsf.edu/pediatric-guidelines-urinary-tract-infections-community-onset

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APPENDIX I: Clinical Pathway for Evaluation of Urinary Tract Infections in Children

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APPENDIX II: History and Physical Resource

The following is a non-exhaustive list of helpful information to obtain in the evaluation of urinary tract infection in pediatric patients.

• HPI:
  • Fever (without another reason/source)
  • Urinary symptoms (dysuria, frequency, urgency, withholding, new incontinence, hematuria)
  • Pain (abdominal, flank, back)
  • PO tolerance/hydration status
  • Stooling history (particularly constipation/withholding)
• PMHx:
  • Elevated blood pressure
  • Poor growth
  • Previous UTI (UTI history should be carefully confirmed to ensure that prior UTIs were not actually contamination/asymptomatic bacteriuria)
  • Vesicoureteral reflux (particularly high-grade)
  • Antenatally diagnosed renal abnormality
  • History of urine withholding
  • Circumcision status
  • History of frequent or recent bladder catheterization
  • History of chronic (or recent) constipation
  • Diaper / toilet training status
• PE:
• Growth (height and weight), development
• Blood pressure
• External GU exam: Evidence of vulvovaginitis or balanitis/posthitis, circumcision status
• Abdominal or flank tenderness
• Evidence of urinary tract obstruction
• Periorbital or extremity edema

 

Northern California Pediatric Hospital Medicine Consortium. Originated 06/2016. Last modified 09/2024.

Approved by UCSF IDMP/Antimicrobial Subcommittee: 4/2018, Med Subcommittee 6/2018

Approved by UCSF Pharmacy and Therapeutics Committee: 8/2018, 12/2024