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Urinary tract infection

What is a Urinary Tract Infection (UTI)?

A urinary tract infection (UTI) is a common bacterial infection which causes illness in infants and children. In children under the age of 3, it can be very difficult to recognise because the signs and symptoms are often non-specific. Lots of children get UTIs but it is important that these infections are accurately diagnosed and treated to reduce the chance of any complications.

Does my child have a UTI?

There are many different signs and symptoms your child may present with when they have a UTI, and these change depending on how old your child is. It is important that you are able to recognise these symptoms and arrange to see your doctor if you are concerned.

How is a UTI diagnosed?

If a UTI is suspected, a sterile urine sample needs to be collected in a specific container given to you by your health practitioner. Diagnosing a UTI in a child under the age of 3 can be difficult because it is challenging to obtain a sterile urine sample.

Dipstick test

Initially, this will be dipstick tested – a stick is dipped in your child’s urine and if there are any white blood cells (leucocytes) or nitrites present, that this may indicate that your child has a UTI, and further tests need to be carried out as these are often present in a typical urinary tract infection.

Urine Culture & Microscopy

If your child is under the age of 3, their urine will be sent for culture and microscopy which will be allow a definitive diagnosis of UTI to be made. Urine culture and microscopy is more reliable than a dipstick test because it allows any bacteria which is causing the infection to be identified, counted and then appropriate treatment can be decided on. It often takes one or two days for the results, and up to 7 days for this information to be relayed back to your health professional.

However, if the dipstick test was positive, your clinician strongly suspects your child has a UTI, or your child has had UTIs in the past, then the clinician may not wait for the results of urine culture and microscopy to come back before initiating treatment.

How are urine samples collected?

It is important that a urine sample is collected correctly as it will affect how your child is treated and investigated. First, wash your hands and the child’s genital area using soap and water. Do not touch the open rim of the bottle/syringe as this could affect the quality of the sample.

Babies

Clean catch: The recommended method of urine collection is a clean catch – have the open bottle ready and catch a urine sample as your baby urinates (often when their nappy is removed). This method requires a lot of patience, but is very good because it minimises the risk of infection.

Urine collection pad: If the clean catch method is unsuccessful, a urine collection pad can be used. Follow the instructions on the pack carefully. It is important to check the pad for urine every 15 minutes and replace it every 30 minutes to avoid contaminating the sample. Once urine has been passed, use the syringe to suck the urine sample from the pad and insert in the bottle provided.

In a very sick baby, a suprapubic catheter (a hollow flexible tube inserted directly into the bladder through a cut in the tummy, a few inches below the belly button) may be inserted to obtain a urine sample.

Toddlers

It is much easier to collect urine from toddlers from a washed up potty than using the clean catch method or a urine collection pad. Ensure that you wash the potty thoroughly in hot water and washing-up liquid, rinse it under a tap and allow it to air dry. There is no need for bleach, antiseptics or rinsing with boiling water – all of these methods are ineffective.

Older children

In older children, the preferred method of urine collection is a mid-stream urine sample (MSU). A mid-stream sample means that the first and the last part of the urine that comes out should not be collected as it can be contaminated with bacteria from either your hands or the skin around your urethra (the tube where urine comes out). Ask your child to start urinating, then collect a sample “mid-stream” in the sterile bottle provided. Disposable sterile plastic funnels may be provided to make this process easier for girls.

A sample using the clean catch method from a cleaned child is usually satisfactory and often easier to collect than MSU.

What happens once urine has been collected?

Treatment

If there is high clinical suspicion and/or initial investigations suggest a UTI, your child will be started on a course of antibiotics for 7-10 days. Usually this is given orally, but if your child is vomiting or not tolerated oral antibiotics, they may require hospital admission to receive these drugs intravenously (through a vein).

In some cases, children may experience recurrent UTIs. This is more likely in younger children (<6 months) and girls. Recurrent UTIs may require further investigation and prophylactic (preventative) antibiotics.

Will my child need any investigations?

Most children who have a UTI have normal kidneys, and they are not harmed during the course of the infection. However, it is sometimes appropriate to carry out different investigations following an infection, in case there is an underlying kidney problem. These investigations include an ultrasound scan of the urinary tract, a DMSA (dimercaptosuccinic acid scan) and/or a bladder x-ray (also called micturating cystourethrogram or MCUG).

An ultrasound scan is a safe and painless test that uses sound waves to make images. Your child’s urinary tract (kidneys, tubes and bladder) will be scanned to check whether they look normal. This test normally takes about 20 minutes and is usually done in the x-ray department of the hospital using a ‘microphone’ and jelly on your child’s tummy.

However, if your child is very young and has kidney scars, an ultrasound scan may not show them very clearly, in which case, your child will need a DMSA scan.

Tests if under 6 months of age

If your child responded to antibiotics within 48 hours of starting then an ultrasound scan is booked for 6 weeks.

If an atypical or unusual infection is found (ie a strange bacteria) then an acute ultrasound scan and DMSA scan are organised at 12 weeks.

Tests done if your child is 6 months -3 years of age

If your child responded to antibiotics within 48 hours of starting then no further imaging is needed.

If an atypical or unusual infection is found (ie a strange bacteria) then an acute ultrasound scan and DMSA scan are organised at 12 weeks.

If your child is getting recurrent infections, then an ultrasound scan is booked at 6 weeks after the infection has cleared and a DMSA scan is organised for 4-6 months following infection.

Follow up

Your child will not need to be followed up if they were diagnosed with a UTI but the imaging tests came back as normal – your doctor will write to you and your GP to let you know if this is the case. However, if the imaging tests show abnormal results, your child has had recurrent UTIs or shows any sign of impaired kidney function, then it is likely that they will need a follow up appointment to monitor their progress. This will all be organised by the healthcare professionals in the hospital and you will be involved every step of the way.

  • MCUG & VCUG
  • Ultrasound Scan
  • DMSA
  • Authors & References

Micturating cystourethrogram (MCUG) is also known as “voiding cystourethrogram” (VCUG). Both “micturating” & “voiding” both mean “passing urine”

What is it?

This test is carried out in the x-ray department and studies how the bladder fills up and then empties.

To do this test a fine tube (catheter) is passed into your child’s bladder through the urethra (the tube through which urine is passed) as in the diagram on the last page. X-ray dye is then put down the tube to show the outline of the bladder. This test is most commonly done in children under 1 year of age.

Why is it done?

We do this test to see if your child has ureteric reflux. This means the urine can pass up from the bladder towards the kidneys. Normally, this should not happen. Ureteric reflux can be a cause of urine infections.

Antibiotics

Doing this test can put germs into the bladder. If your child is on Trimethoprim antibiotics you will need to give twice the normal dose on the morning of the test. Repeat this dose in the evening of the test and twice a day for the next 2 days. Then go back to the normal dose.

If your child is not on an antibiotic, or is on another one, please contact your paediatrician to ask what you should do.

What do we do?

You and your child will be given an appointment to go to the X Ray Department at. He or she will have the catheter passed by either a Paediatric nurse or doctor. This can sometimes be difficult in babies and can be uncomfortable. We do not give sedation as past experience tells us that this doesn’t usually work well. It often means a longer hospital stay as well. A local anaesthetic gel is used during the insertion of the catheter to ease any discomfort. You will be able to stay with your baby throughout the test.

The catheter will be taped in. You may be asked to feed your baby at this point to try and settle him/her.

The X-ray doctor will then put the dye down the catheter. This will distend the bladder and therefore may hurt for a short time. X-rays will be taken, these do not hurt. This normally takes about 15 minutes.

The catheter will be removed after the test. We may be able to tell you the results before you go home. If reflux is shown, your child may be started on a course of antibiotics. For this reason it would be helpful if your child could be weighed up to a week prior to your appointment by the health visitor and documented in your child’s red book, which we ask you to bring with you to your appointment.

If the results are not available on the day, your paediatrician will let you know them later at an outpatient appointment.

An ultrasound scan is a safe and painless test that uses sound waves to make images. Your child’s urinary tract (kidneys, tubes and bladder) will be scanned to check whether they look normal. This test normally takes about 20 minutes and is usually done in the x-ray department of the hospital using a ‘microphone’ and jelly on your child’s tummy.

However, if your child is very young and has kidney scars, an ultrasound scan may not show them very clearly, in which case, your child will need a DMSA scan.

DMSA stands for dimercaptosuccinic acid, it is a radioactive substance (called a tracer) that is injected into a vein and enters the kidneys. It is allows a scan to be taken of the inside of the kidneys.

This test is carried out between 4 and 6 months after the urine infection was diagnosed. A small amount of radioactive material, called DMSA, is injected into your child’s vein – don’t worry, we can put some ‘magic’ (local anaesthetic) cream on beforehand so that this does not cause your child any pain. Usually, a blood test will be done at the same time to check your child’s kidney function.

After 2 hours, in which your child can play, eat and drink normally, the DMSA collects in the kidneys and pictures of their organs are taken with a special camera. If there is any scarring in the kidneys, this scan helps to show that.

Although DMSA is radioactive, it is only a very small quantity that is injected into the veins so will not expose your child to any more radiation than an ordinary x-ray.

Authors

Trish Ogunmakin & Tim Ubhi

Review date

June 2019

References

http://www.rcpch.ac.uk/sites/default/files/asset_library/Research/Clinical%20Effectiveness/Endorsed%20guidelines/Urinary%20Tract%20Infection%20in%20Children%20%28NICE%29/NICE%20UTI%20Guideline.pdf

http://patient.info/doctor/urinary-tract-infection-in-children

http://kidshealth.org/en/parents/ultrasound-abdomen.htmlhttp://www.aviva.co.uk/health-insurance/home-of-health/medical-centre/medical-encyclopedia/entry/test-dmsa-scanning/