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

In depth

• If urinary tract infection (UTI) — upper or lower — is suggested by symptoms or by urine tests, treat immediately with an antibiotic.
• Before starting antibiotics send a urine specimen for culture and sensitivities unless the child has typical cystitis, or the child has no specific symptoms of UTI, is at low risk for serious illness, and the urine dipstick test is negative for both nitrite and leukocyte esterase.
• Delay the decision about treatment until the urine microscopy and culture results are available when there are no specific symptoms for UTI and 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).
• Do not treat (and do not send urine for culture) if the child has no symptoms specific for UTI, and if the urine dipstick test is negative for both nitrite and leukocyte esterase.

In depth

• Treat with an oral antibiotic for 3 days.
• Consider trimethoprim, nitrofurantoin, cefalexin or amoxicillin, while taking local bacterial sensitivity patterns into account (this is an off licence use of nitrofurantoin as the summary of product characteristics specifies 7 days).
• 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.
• Treat pain with paracetamol — avoid NSAIDs.
• Encourage (and monitor) adequate fluid intake.

In depth

• Treat with an oral antibiotic for 7–10 days (provided that they do not require admission, are not vomiting, and parents are reliable).
• Consider co-amoxiclav or cefalexin, while taking local bacterial sensitivity patterns into account.
• Treat fever and pain with paracetamol — avoid NSAIDs.
• Obtain a urine specimen for culture before starting antibiotic treatment.
• Encourage (and monitor) adequate fluid intake.

In depth

• 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.

In depth

• Routinely review with the culture result (e.g. at around 48 hours). This can be done by telephone, but if the child is not responding to treatment, he or she should be brought in for reassessment.
• 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 infant or child has poor response to appropriate treatment, or suspected urinary tract obstruction.
• Refer non-urgently to a paediatric specialist if there has been previous urinary tract infection.

In depth