• Suspect UTI if the child has any combination of:
• Frequency, dysuria (most common presentation in verbal children).
• Fever without an obvious cause (most common presentation in preverbal children).
• Fever with a presumed cause but poor response to treatment.
• Abdominal pain, loin tenderness. Vomiting, poor feeding. Malaise, lethargy, irritability. Haematuria, offensive urine, cloudy urine. Failure to thrive.
• Dysfunctional voiding (voluntary withholding of urine or faeces), incontinence of urine or faeces. New onset of bedwetting.

In depth

• Make a preliminary diagnosis on the basis of the clinical symptoms and urine dipstick test (or, if available, urgent microscopy).
• Confirm the diagnosis with urine culture.

In depth

• Children with suspected urinary tract infection (UTI) are at high risk of serious illness if:
• They are systemically unwell, dehydrated, or vomiting and cannot tolerate oral fluids and medication.
• Have a history or clinical features suggesting urinary tract obstruction.
• Children with suspected UTI are at intermediate risk of serious illness if:
• They are not at high risk, and they do not satisfy all the criteria for being at low risk.
• Children with suspected UTI are at low risk of serious illness if:
• Temperature is less than 38°C with no history of fever and there is no loin pain/tenderness.
• Colour, cry, responsiveness, and hydration are normal.

In depth

• Make a working diagnosis of upper UTI (acute pyelonephritis) if there is:
• Fever of greater than 38°C (or history of fever) and bacteriuria, or
• Fever of less than 38°C (and no history of fever), loin tenderness, and bacteriuria.
• Otherwise, diagnose lower UTI (cystitis), which in older children usually presents with specific symptoms (frequency, dysuria, lower abdominal pain).

In depth

• 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