Urinary tract infection in

under 16s: diagnosis and

management
Re-audit of NICE guideline CG54
Dr Wis Wang-Koh and Dr Birgit Ulbrich
July 2017

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Introduction
• This is a re-audit of NICE guideline CG54 evaluating
diagnosis, treatment and follow up investigation in children
with suspected urinary tract infection in 2015.

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Objectives
• Our aim was to evaluate our service and see how well we
comply with NICE guidance, that is the best available
evidence, to manage paediatric patients with urinary tract
infections (UTIs) in the acute setting. We hope that this
will improve the treatment of UTIs, as well as highlight any
areas that can be improved on.
• By regularly auditing our management, we hope to ensure
that patients are receiving correct follow up and any
urinary tract abnormalities are identified early.
• We also hope to improve staff awareness of the best
action to take when suspecting and diagnosing UTIs in
paediatric patients.

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Sample & exclusions
• Random selection of 25 patients under 16 years of age
who were given a clinical code of “urinary tract infection”
or “cystitis” or “pyelonephritis” between January 2015 and
December 2015
• Included emergency department, ward patients, oncology
patients and patients with renal abnormalities (not
necessarily first presentation of UTI)
• 4 patients were removed from audit as no evidence found
of UTI in 2015

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Method
• Random selection of patient numbers obtained from
clinical audit
• Retrospective evaluation of medical notes through e-
hospital system.

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Standards

Critera Standard

1. Infants and children presenting with unexplained fever of 38°C or 100%

higher should have a urine sample tested after 24 hours at the latest

2. Infants and children with symptoms and signs suggestive of urinary 100%
tract infection (UTI) should have a urine sample tested for infection

3. Urine collection: clean catch, catheter or suprapubic aspiration 100%

sample.

4. Before SPA is attempted, ultrasound guidance should be used to 100%

demonstrate the presence of urine in the bladder.

5. Infants younger than 3 years with suspected UTI should have a urine 100%
sample sent for urgent microscopy and culture

6. Children older than 3 years with suspected UTI should have a urine 100%
dipstick tested for leukocyte esterase and nitrites
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Standards

Criteria Standard

7. Risk factors for UTI and serious underlying pathology should be 100%
recorded (for detail, see results section)

8. Infants younger than 3 months with a possible UTI should be treated 100%
with parenteral antibiotics

9. Infants and children 3 months or older with acute pyelonephritis/upper 100%

urinary tract infection should be treated with oral antibiotics for 7–10 days

10. Infants and children 3 months or older with cystitis/lower urinary tract 100%
infection should be treated with oral antibiotics for 3 days

11. Asymptomatic bacteriuria in infants and children should not be treated 100%
with antibiotics

12. For infants younger than 6 months with first-time UTI that responds to 100%
treatment, ultrasound should be carried out within 6 weeks of the UTI

13. A DMSA scan 4–6 months following the acute infection should be 100%
used to detect renal parenchymal defects
Results

Critera Standard Result

1. Infants and children presenting with unexplained fever of 100% 100%

38°C or higher should have a urine sample tested after
24 hours at the latest
2. Infants and children with symptoms and signs suggestive of 100% 100%
urinary tract infection (UTI) should have a urine sample tested
for infection
3. Urine collection: clean catch, catheter or suprapubic 100% 57%
aspiration sample.

4. Before SPA is attempted, ultrasound guidance should be 100% N/A

used to demonstrate the presence of urine in the bladder.

5. Infants younger than 3 years with suspected UTI should 100% 100%
have a urine sample sent for urgent microscopy and culture

6. Children older than 3 years with suspected UTI should have 100% 100%
a urine dipstick tested for leukocyte esterase and nitrites
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Results

Criteria Standard Results

7. Risk factors for UTI and serious underlying pathology 100% See next
should be recorded (for detail, see results section) page
8. Infants younger than 3 months with a possible UTI should 100% N/A
be treated with parenteral antibiotics

9. Infants and children 3 months or older with acute 100% 100%

pyelonephritis/upper urinary tract infection should be treated
with oral antibiotics for 7–10 days

10. Infants and children 3 months or older with cystitis/lower 100% 93%
urinary tract infection should be treated with oral antibiotics for
3 days
11. Asymptomatic bacteriuria in infants and children should not 100% 100%
be treated with antibiotics

12. Renal ultrasound carried out in accordance with 100% 60%

recommended imaging schedule

13. A DMSA scan 4–6 months following the acute infection 100% 100%
should be used to detect renal parenchymal defects
Results
• Criteria 7 result breakdown:
Risk
Percentage
factor/underlying Standard Result
in 2014
pathology
Urine flow 100% 13% 19%
Previous UTI 100% 27% 31%
Recurrent fever of
100% 55% 0%
uncertain origin
Bowel habit 100% 27% 0%
Palpable bladder 100% 13% 0%
Blood pressure 100% 41% 19%
Results (cont.)
• 43% of all urine samples had no method of collection
documented.
• There were no records of any urine sample obtained by
suprapubic aspiration in our sample, so we were unable to
investigate the use of ultrasound before aspiration.
• There were no patients in this sample who were under 3
months of age, so we could not measure treatment for this age
group.
• One patient who had a recurrent asymptomatic bacteriuria was
not treated with antibiotics, thereby bringing the result of
treated UTIs to 93% overall, but NICE guidance also says that
asymptomatic bacteriuria should not be treated.
Results (cont.)
• We note that documentation of the risk factors and
underlying pathology that is recommended in the history
and examination is variable. However it is to be noted
that one patient in the sample was transferred in to the
paediatric intensive care unit (PICU) intubated and
ventilated, and there was no history of symptoms to be
obtained.
• Two of the urine samples that had positive cultures were
incidental findings, as the patients had not complained of
any symptoms of UTI. There was therefore no specific
history documented.
For our interest, we detailed antibiotic resistance in the urine cultures with positive bacterial growth.
It is noted that not all cultures had co-amoxiclav sensitivity status documented. This is the current
first-line antibiotic in the trust guidelines.
S = sensitive, R = resistant
Growth Trimethoprim Gentamicin Amoxicillin Nitrofurantoin Co-amoxiclav Other
sensitivity
Enterococcus R R Vancomycin
Proteus S S S R
E.coli R R R S S
E.coli S R S
Ceftazidime
Pseudomonas S
tazocin
E.coli S S S S S
ESBL R S R S
Klebsiella S S R S S
Ciprofloxacin
Psuedomonas S
tazocin
E.coli S S R S S
Enterobacter Multidrug
R R R R R
cloacae resistant
E.coli S S R S S

Resistance 33% 20% 80% 30% 17%

Conclusions

• Initial investigation for potential UTI with urine dipstick and

microscopy and culture is good
• We need to document the method of urine sampling
• There is lack of detail in histories with regard to urine flow,
previous UTIs and change in bowel habit. Examination
records are lacking documentation of the blood pressure
and if there is a palpable bladder or not.
• We have improved since the 2014 audit.

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Recommendations

• Remind all ED and ward staff to document method of

urine sampling when sample taken

• Remind paediatric and ED doctors to take detailed

history for urinary symptoms and to document
positive and negative findings on examination

• Re-audit 2017/2018

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Action Plan
By By
Recommendation Action required
whom? when?

Regularly
Documentation of negative Dr Birgit during SHO
Teaching medical staff
findings in notes Ulbrich teaching
time

Clarification of method of urine Will be assessed in the Dr Ruth

2017
collection upcoming Sepsis audit Clay

Check with microbiology lab

that they are testing all urine
Dr Ulbrich will email Dr August
cultures with common bacterial Dr Ulbrich
Sani Aliyu 2016
growths for co-amoxiclac
sensitivity

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