• Maintain a high index of suspicion for urinary tract infection (UTI).
• Assess the risk of severe illness.
• Refer or admit urgently when:
• The infant is less than 3 months of age, or
• The risk of severe illness is high for other reasons.
• Collect a urine sample using the most appropriate method for the child.
• Make a preliminary diagnosis by testing the urine:
• Urgent urine microscopy (if available) for infants and children less than 3 years of age.
• Dipstick test for children from the age of 3 years onward (or urgent microscopy if available).
• Culture the urine for all children suspected of UTI, except children over 3 years of age with low risk of serious illness who also:
• Have typical uncomplicated first lower UTI (cystitis), or
• Have had UTI excluded by urine dipstick tests (or urgent microscopy).
• Determine the level of infection (upper or lower UTI).
• Assess the risk of serious underlying abnormalities.
• Treat:
• Upper UTI (acute pyelonephritis) with an oral antibiotic for 7–10 days (most infants and children will require referral to a paediatric specialist).
• Lower UTI (cystitis) with an oral antibiotic for 3 days.
• Arrange imaging tests if indicated — this is seldom necessary in primary care because most infants and children who require imaging are already being managed in secondary care.
• Refer for follow up in secondary care infants and children with:
• Recurrent UTI.
• Risk factors for serious underlying abnormality.
• Atypical illness (e.g. inadequate response to treatment).
• Abnormal imaging results.
• Prophylactic antibiotics are rarely indicated and should not be initiated in primary care.
• Urine culture for 'test of cure' after treatment is not routinely recommended.

• Urgently admit all infants less than 3 months of age if urinary tract infection is suspected.
• Urine testing is not necessary in primary care as this will not change management.

This recommendation is based on National Institute for Health and Clinical Excellence guidelines [National Collaborating Centre for Women's and Children's Health, 2007], which in turn are largely based on expert opinion on the balance of risks and benefits of invasive tests and treatments:

• Young infants with suspected urinary tract infection are at increased risk for severe illness.
• Therefore, admission is required to:
• Obtain a urine sample (which may require catheterization of the bladder or suprapubic aspiration of the bladder).
• Perform urgent urine microscopy.
• Treat with parenteral antibiotics, if these are indicated.

• Imaging tests used to investigate children with urinary tract infection include ultrasonography of the kidneys, ureters, and bladder; DMSA (dimercaptosuccinic acid) scintigraphy; and micturating cystourethrography.
• In primary care, it is rarely necessary to arrange (or refer for) imaging tests because the infants who require an imaging test should already be being managed in secondary care. For ease of reference, Table 1 lists the criteria for imaging that are recommended by NICE [National Collaborating Centre for Women's and Children's Health, 2007].

For further information, see Atypical urinary tract infection, and Recurrent urinary tract infection.

• Urgently refer or admit infants and children between 3 months and 3 years of age if they have a urinary tract infection (UTI) and are at high risk for serious illness.
• Consider urgent referral for infants and children at intermediate risk for serious illness.

• For more information on diagnosis and assessment see:
• When to suspect urinary tract infection
• Confirming diagnosis
• Interpreting urine test results
• Assessing risk of serious illness
• Determining lower or upper UTI

These recommendations are based on the National Institute for Health and Clinical Excellence guideline Urinary tract infection in children: diagnosis, treatment and long-term management [National Collaborating Centre for Women's and Children's Health, 2007].

For infants and children older than 3 months and younger than 3 years who have a urinary tract infection (UTI) and do not need urgent referral/admission:

• Obtain a urine specimen for culture and sensitivities prior to starting antibiotics.
• Treat immediately with an antibiotic:
• For upper UTI (acute pyelonephritis) if:
• Fever of greater than 38°C and bacteriuria, or
• Fever of less than 38°C and loin pain/tenderness and bacteriuria.
• For lower UTI (cystitis) if:
• Specific symptoms of cystitis (e.g. frequency dysuria), or
• Non-specific symptoms of UTI and bacteriuria present on urgent microscopy (or, if urgent microscopy is not available, nitrite positive with urine dipstick test).
• Delay the decision about treating with an antibiotic until the results of urine culture and routine microscopy are available:
• For infants and children who have no specific symptoms for UTI, and are at:
• Intermediate risk for severe illness, and urgent urine microscopy shows no bacteriuria or leukocytes (or, if urgent microscopy is not available, the urine dipstick tests for nitrite and leukocyte esterase are negative).
• Low risk for serious illness (urgent microscopy is not needed).

• Most infants and children with upper urinary tract infection (acute pyelonephritis) will need to be admitted for treatment in secondary care.

These recommendations are based on the National Institute for Health and Clinical Excellence guideline Urinary tract infection in children: diagnosis, treatment and long-term management [National Collaborating Centre for Women's and Children's Health, 2007].

• Treat with an oral antibiotic for 3 days.
• The choice of antibiotic should be guided by local information on antibiotic resistance patterns of urinary pathogens.
• Antibiotics that may be suitable include:
• Trimethoprim
• Nitrofurantoin — a course of 3 days is 'off-licence'
• Cefalexin
• Amoxicillin
• Note: avoid using broad spectrum antibiotics (e.g. cephalosporins) when narrow spectrum antibiotics are effective, as they increase the risk of Clostridium difficile, MRSA, and resistant UTIs.
• If the infant or child has pain, treat with paracetamol.
• Encourage (and monitor) adequate fluid intake.

• If the infant or child has developed the urinary tract infection while on prophylactic antibiotic treatment, treat with a different antibiotic.
• If possible, obtain a urine specimen for culture before starting antibiotic treatment.
• Avoid ibuprofen and other NSAIDs for the symptomatic treatment of pain or fever, as they can cause renal complications.

These recommendations are based on clinical guidelines on Urinary tract infection in children, published by the National Institute for Health and Clinical Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2007].

Antibiotic choice:

• NICE did not identify any controlled trials that investigated the efficacy of antibiotics in the treatment of children with cystitis. They recommend that the choice of antibiotic should be directed by 'locally developed multidisciplinary guidance' where possible.
• Trimethoprim, nitrofurantoin, a cephalosporin, or amoxicillin are recommended on the basis of the 'available evidence and current clinical practice'. There is no guidance on which of these antibiotics should be selected; however, any contraindications or cautions the child has should also be taken into account.
• If a cephalosporin is selected, CKS recommends cefalexin, as it is most commonly used, has a convenient dosing schedule, and is relatively inexpensive. However, other cephalosporins, such as cefadroxil, cefaclor, or cefixime, are suitable alternatives.
• The Health Protection Agency (HPA) recommends avoiding broad spectrum antibiotics (e.g. co-amoxiclav, quinolones, and cephalosporins) when narrow spectrum antibiotics remain effective, as broad spectrum antibiotics increase the risk of Clostridium difficile, MRSA, and resistant UTIs [HPA and Association of Medical Microbiologists, 2008].

Antibiotic duration:

• NICE states that 'there is no difference in outcomes for children treated with cystitis with short-duration antibiotics compared with long-duration antibiotics'. They recommend a 3-day regimen for all the suggested antibiotics. However, the product license for nitrofurantoin specifies 7 days [MCA, 2002].
• Children who fail to improve within this period should be followed up and their antibiotics switched according to culture results, or referral can be considered.

Most infants and children with an upper urinary tract infection (UTI) (acute pyelonephritis) should be urgently referred/admitted for treatment. However, if they can safely be managed in primary care and if there is no vomiting or diarrhoea that would impair drug absorption:

• Treat with an oral antibiotic for 7–10 days.
• The choice of antibiotic should be guided by local information on antibiotic resistance patterns of urinary pathogens.
• If the infant or child has developed the UTI while on prophylactic antibiotic treatment, treat with a different antibiotic.
• Antibiotics that may be suitable include:
• Co-amoxiclav.
• Cefalexin.
• Treat fever or pain with paracetamol.
• Obtain a urine specimen for culture before starting antibiotic treatment.
• Encourage (and monitor) adequate fluid intake.

• For infants and children with suspected upper urinary tract infection (acute pyelonephritis), it is prudent to adopt a low threshold for referral to specialist care. For further information, see Urgent referral or admission.
• For information on dose and contraindications or adverse effects that may influence prescribing, see sections on co-amoxiclav and cefalexin. If neither drug is suitable, for instance if the infant or the child has a documented allergy to penicillin, seek specialist advice.
• Avoid ibuprofen and other NSAIDs for the symptomatic treatment of pain or fever, as they can cause renal complications.

These recommendations are based on clinical guidelines on Urinary tract infection in children, published by the National Institute for Health and Clinical Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2007].

• NICE recommend that the choice of antibiotic, route of administration and the duration of treatment be made according to the clinical presentation and local sensitivity patterns. The aim is to eradicate the infection, relieve symptoms and minimize the development of renal parenchymal defects.

Antibiotic choice:

• There is little evidence from controlled trials with which to guide antibiotic selection for children with pyelonephritis. NICE identified four randomized controlled trials (RCTs) that addressed this issue, but all compared intravenous antibiotics and failed to show superiority of one antibiotic compared with another.
• NICE recommend that the choice of antibiotic should be guided by local policies in accordance with the local microbiology laboratory (where resistance patterns have been monitored).
• Co-amoxiclav or a 'first-generation' cephalosporin is recommended by CKS, as there is usually low resistance patterns for these antibiotics. If a cephalosporin is selected, CKS recommends cefalexin, as it is most commonly used, has a convenient dosing schedule, and is relatively inexpensive. However, other cephalosporins, such as cefadroxil, cefaclor, or cefixime, are suitable alternatives.

Antibiotic duration:

• NICE failed to identify any RCTs that investigated the optimal duration of antibiotics for children with pyelonephritis. They concluded that in the absence of concrete evidence, common current UK practice should be used, which is treatment for 7–10 days. This is a shorter duration than is commonly used in some countries, but has several theoretical advantages such as improved compliance, reduced adverse effects, and decreased emergence of antibiotic-resistant organisms, although this has not been observed in practice. CKS recommends a course of 7 days for pragmatic reasons.
• The Health Protection Agency recommends for acute pyelonephritis (without specifying the age) a 14-day course of co-amoxiclav (or trimethoprim, if susceptible), or a 7–day course of ciprofloxacin (which is best avoided in growing children; there are also concerns in the UK about increasing bacterial resistance) [HPA, 2006].

Routinely review with the culture result (e.g. at around 48 hours) to ensure that the infant or child is responding to treatment, and to reassess the choice of antibiotic. This can be done by telephone:

• What if the infant or child is responding but the culture isolated an organism that is resistant to the chosen antibiotic?
• For upper urinary tract infection, switch to an antibiotic to which the organism is sensitive.
• For lower urinary tract infection, consider completing the course of the original antibiotic and doing a 'test of cure' urine culture when the course has been completed.
• However, some experts recommend always switching to an antibiotic to which the organism is sensitive.
• What if the infant or child is still unwell after 24–48 hours on antibiotic treatment?
• Advise the parents/caregivers to bring him or her in for assessment.
• If an alternative diagnosis is made, manage accordingly.
• If an alternative diagnosis is not made, and:
• Urine culture has isolated an organism resistant to the antibiotic being taken, switch to an antibiotic to which the organism is sensitive.
• Urine culture was not done or does not suggest a more appropriate antibiotic, send a urine sample for culture to identify the presence of bacteria and determine antibiotic sensitivity.
• What if the infant or child has responded well and is no longer symptomatic?
• Do not send urine for culture as a 'test of cure'.
• Do not start prophylactic antibiotics; these are rarely necessary. If prophylactic antibiotics are thought to be indicated, refer or consult a paediatric specialist.

Refer urgently to a paediatric specialist if the infant or child has:

• Poor response to appropriate treatment.
• A history or clinical features suggesting urinary tract obstruction, such as:
• High blood pressure.
• Poor growth.
• Poor urine flow.
• Recurrent fever of uncertain origin.
• Antenatally-diagnosed renal abnormality.
• Family history of vesicoureteral reflux or renal disease.
• Enlarged bladder.
• Abdominal mass.
• Evidence of spinal lesion.

Refer non-urgently to a paediatric specialist if the infant or child:

• Is less than 6 months old, or has:
• Has a history of urinary tract infection (probable or confirmed).

• Infants and children who require imaging tests are included in those who should be referred for specialist assessment.

These recommendations are based on the National Institute for Health and Clinical Excellence guideline Urinary tract infection in children: diagnosis, treatment and long-term management [National Collaborating Centre for Women's and Children's Health, 2007].

Advise parents/caregivers that:

• They should telephone or return to get the urine culture results when these are expected to be available.
• Most children are well 24–48 hours after starting treatment. If the infant or child is still unwell after 24–48 hours, they should return for reassessment.
• Once the infant or child has recovered, they should be alert to the uncommon possibility of a repeat urinary tract infection (UTI). If they suspect a repeat UTI, they should seek medical assessment without delay.
• Infants and children who are 6 months or older, who respond well to treatment and do not have any other unusual features, do not need any further tests unless they have further UTIs.

These recommendations are based on the National Institute for Health and Clinical Excellence guideline Urinary tract infection in children: diagnosis, treatment and long-term management [National Collaborating Centre for Women's and Children's Health, 2007].

• Imaging tests used to investigate children with urinary tract infection include ultrasonography of the kidneys, ureters, and bladder; DMSA (dimercaptosuccinic acid) scintigraphy; and micturating cystourethrography.
• In primary care, it is rarely necessary to arrange (or refer for) imaging tests because the infants or children who require an imaging test are usually already being managed in secondary care. However, the criteria recommended by NICE for imaging with a urinary tract infection are summarized in the sections:
• NICE imaging schedule for infants less than 6 months
• NICE imaging schedule for children between 6 months and 3 years

For further information, see Atypical urinary tract infection, and Recurrent urinary tract infection.

For further information, see Atypical urinary tract infection, and Recurrent urinary tract infection.

• If the child is at high risk for serious illness — urgently refer/admit.
• If the child is at intermediate risk for serious illness — consider urgent referral/admission.

• For more information on diagnosis and urine tests see:
• When to suspect urinary tract infection
• Confirming diagnosis
• Interpreting urine test results
• Determining lower or upper UTI
• Assessing risk of serious illness

These recommendations are based on the National Institute for Health and Clinical Excellence guideline Urinary tract infection in children: diagnosis, treatment and long-term management [National Collaborating Centre for Women's and Children's Health, 2007].

For children over 3 years of age who have a suspected urinary tract infection (UTI) and do not need urgent referral/admission:

• Treat immediately with an antibiotic:
• For upper UTI (acute pyelonephritis) if:
• Fever of greater than 38°C and bacteriuria (or nitrite positive on urine dipstick test), or
• Fever of less than 38°C and loin pain/tenderness and bacteriuria (or nitrite positive on urine dipstick test).
• For lower UTI (cystitis) if:
• Specific symptoms of cystitis (e.g. frequency and dysuria), or
• Non-specific symptoms of UTI and nitrite positive with urine dipstick test (or bacteriuria present on urgent microscopy).
• Before starting antibiotics send a urine specimen for culture and sensitivities unless:
• The child has typical symptoms of uncomplicated cystitis, or
• The child has no specific symptoms of UTI, and is at low risk for serious illness, and the urine dipstick test is negative for both nitrite and leukocyte esterase.
• Delay the decision about antibiotic treatment for lower UTI (cystitis) until the results of urine culture and microscopy are available if the child has no specific symptoms of UTI and if the immediate urine test is equivocal (i.e. dipstick negative for nitrites but positive for leukocyte esterase, or microscopy showed no bacteriuria but found pyuria).

• Most children with upper urinary tract infection (acute pyelonephritis) will need to be admitted for treatment in secondary care.

These recommendations are based on the National Institute for Health and Clinical Excellence guideline Urinary tract infection in children: diagnosis, treatment and long-term management [National Collaborating Centre for Women's and Children's Health, 2007].

• Treat with an oral antibiotic for 3 days.
• The choice of antibiotic should be guided by local information on antibiotic resistance patterns of urinary pathogens.
• Antibiotics that may be suitable include:
• Trimethoprim
• Nitrofurantoin — a course of 3 days is 'off-licence'
• Cefalexin
• Amoxicillin
• Note: avoid using broad spectrum antibiotics (e.g. cephalosporins) when narrow spectrum antibiotics are effective, as they increase the risk of Clostridium difficile, MRSA, and resistant UTIs.
• If the child has pain, treat with paracetamol.
• Encourage (and monitor) adequate fluid intake.

• If the child has developed the urinary tract infection while on prophylactic antibiotic treatment, treat with a different antibiotic.
• If possible, obtain a urine specimen for culture before starting antibiotic treatment.
• Avoid ibuprofen and other NSAIDs for the symptomatic treatment of pain or fever, as they can cause renal complications.

These recommendations are based on clinical guidelines on Urinary tract infection in children, published by the National Institute for Health and Clinical Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2007].

Antibiotic choice:

• NICE did not identify any controlled trials that investigated the efficacy of antibiotics in the treatment of children with cystitis. They recommend that the choice of antibiotic should be directed by 'locally developed multidisciplinary guidance' where possible.
• Trimethoprim, nitrofurantoin, a cephalosporin, or amoxicillin are recommended on the basis of the 'available evidence and current clinical practice'. There is no guidance on which of these antibiotics should be selected; however, any contraindications or cautions the child has should also be taken into account.
• If a cephalosporin is selected, CKS recommends cefalexin, as it is most commonly used, has a convenient dosing schedule, and is relatively inexpensive. However, other cephalosporins, such as cefadroxil, cefaclor, or cefixime, are suitable alternatives.
• The Health Protection Agency (HPA) recommends avoiding broad spectrum antibiotics (e.g. co-amoxiclav, quinolones, and cephalosporins) when narrow spectrum antibiotics remain effective, as broad spectrum antibiotics increase the risk of Clostridium difficile, MRSA, and resistant UTIs [HPA and Association of Medical Microbiologists, 2008].

Antibiotic duration:

• NICE states that 'there is no difference in outcomes for children treated with cystitis with short-duration antibiotics compared with long-duration antibiotics'. They recommend a 3-day regimen for all the suggested antibiotics. However, the product license for nitrofurantoin specifies 7 days [MCA, 2002].
• Children who fail to improve within this period should be followed up and switching antibiotics according to culture results or referral can be considered.

Most children with an upper urinary tract infection (UTI) (acute pyelonephritis) should be urgently referred/admitted for treatment. If they can safely be managed in primary care (i.e. low risk for severe illness, not vomiting, and parents are reliable):

• Treat with an oral antibiotic for 7–10 days.
• The choice of antibiotic should be guided by local information on antibiotic resistance patterns of urinary pathogens.
• If the child has developed the UTI while on prophylactic antibiotic treatment, treat with a different antibiotic.
• Antibiotics that may be suitable include:
• Co-amoxiclav.
• Cefalexin.
• Treat fever or pain with paracetamol.
• Obtain a urine specimen for culture before starting antibiotic treatment.
• Encourage (and monitor) adequate fluid intake.

• For children with suspected upper urinary tract infection (acute pyelonephritis), it is prudent to adopt a low threshold for referral to specialist care. For further information, see Urgent referral or admission.
• For information on contraindications or adverse effects that may influence prescribing, see the sections on co-amoxiclav and cefalexin. If neither drug is suitable, for instance the child has a documented allergy to penicillin, seek specialist advice.
• Avoid ibuprofen and other NSAIDs for the symptomatic treatment of pain or fever, as they can cause renal complications.

These recommendations are based on clinical guidelines on Urinary tract infection in children, published by the National Institute for Health and Clinical Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2007].

• NICE recommend that the choice of antibiotic, route of administration and the duration of treatment be made according to the clinical presentation and local sensitivity patterns. The aim is to eradicate the infection, relieve symptoms and minimize the development of renal parenchymal defects.

Antibiotic choice:

• There is little evidence from controlled trials to guide antibiotic selection for children with pyelonephritis. NICE identified four randomized controlled trials (RCTs) that addressed this issue, but all compared intravenous antibiotics and failed to show superiority of one antibiotic compared with another.
• NICE recommend that the choice of antibiotic should be guided by local policies in accordance with the local microbiology laboratory (where resistance patterns have been monitored).
• Co-amoxiclav or a 'first-generation' cephalosporin is recommended by CKS, as there is usually low resistance to these antibiotics. If a cephalosporin is selected, CKS recommends cefalexin, as it is most commonly used, has a convenient dosing schedule, and is relatively inexpensive. However, other cephalosporins, such as cefadroxil, cefaclor, or cefixime, are suitable alternatives.

Antibiotic duration:

• NICE did not identify any RCTs that investigated the optimal duration of antibiotics for children with pyelonephritis. They concluded that in the absence of concrete evidence, common current UK practice should be used, which is treatment for 7–10 days. This is a shorter duration than is commonly used in some countries, but has several theoretical advantages, such as improved compliance, reduced adverse effects, and decreased emergence of antibiotic-resistant organisms, although this has not been observed in practice. CKS recommend a course of 7 days duration for pragmatic reasons.
• The Health Protection Agency recommends for acute pyelonephritis (without specifying the age) a 14-day course of co-amoxiclav (or trimethoprim, if susceptible), or a 7–day course of ciprofloxacin (which is best avoided in growing children; there are also concerns in the UK about increasing bacterial resistance) [HPA, 2006].

Routinely review with the culture result (e.g. at around 48 hours) to ensure that the child is responding to treatment, and to reassess the choice of antibiotic. This can be done by telephone.

• What if the child is responding but the culture isolated an organism that is resistant to the chosen antibiotic?
• Many experts, but not all, would recommend switching to a antibiotic to which the organism is sensitive.
• If the decision is to continue with the original antibiotic, do a 'test of cure' urine culture after the the course of antibiotic has been completed.
• What if the child is still unwell after 24–48 hours on antibiotic treatment?
• Advise the parents/carers to bring him or her in for assessment.
• If an alternative diagnosis is made, manage accordingly.
• If an alternative diagnosis is not made, and:
• Urine culture has isolated an organism resistant to the antibiotic being taken, switch to antibiotic to which the organism is sensitive.
• Urine culture was not made or does not suggest a more appropriate antibiotic, send a urine sample for culture to identify the presence of bacteria and determine antibiotic sensitivity.
• What if the child has responded well and is no longer symptomatic?
• Do not send urine for culture as a 'test of cure'.
• Do not start prophylactic antibiotics; these are rarely necessary. If prophylactic antibiotics are thought to be indicated, refer or consult a paediatric specialist.

Refer urgently to a paediatric specialist if the child has:

• Poor response to appropriate treatment.
• A history or clinical features suggesting urinary tract obstruction, such as:
• High blood pressure.
• Poor growth.
• Poor urine flow.
• Recurrent fever of uncertain origin.
• Antenatally-diagnosed renal abnormality.
• Family history of vesicoureteral reflux or renal disease.
• Enlarged bladder.
• Abdominal mass.
• Evidence of spinal lesion.

Refer non-urgently to a paediatric specialist if the child has:

• History of urinary tract infection (probable or confirmed).

• Children who should undergo imaging tests are included in those who should be referred for specialist assessment.

These recommendations are based on the National Institute for Health and Clinical Excellence guideline Urinary tract infection in children: diagnosis, treatment and long-term management [National Collaborating Centre for Women's and Children's Health, 2007].

Advise parents/caregivers that:

• They should telephone or return to get the urine culture results when these are expected to be available.
• Most children are well 24–48 hours after starting treatment. If the infant or child is still unwell after 24–48 hours, they should return for reassessment.
• Once the infant or child has recovered, they should be alert to the uncommon possibility of a repeat urinary tract infection (UTI). If they suspect a repeat UTI, they should seek medical assessment without delay.
• Children 3 or more years old who respond well to treatment and do not have any other unusual features, do not need any further tests unless they have further UTIs.

These recommendations are based on the National Institute for Health and Clinical Excellence guideline Urinary tract infection in children: diagnosis, treatment and long-term management [National Collaborating Centre for Women's and Children's Health, 2007].

• Imaging tests used to investigate children with urinary tract infection include ultrasonography of the kidneys, ureters, and bladder; DMSA (dimercaptosuccinic acid) scintigraphy; and micturating cystourethrography.
• In primary care, it is rarely necessary to arrange (or refer for) imaging tests because the infants or children that require an imaging test are usually already being managed in secondary care. However, the recommended criteria for imaging are listed in Table 1 for ease of reference.

For further information, see Atypical urinary tract infection, and Recurrent urinary tract infection.