SYMPOSIUM: NEPHROLOGY
Urinary tract infections in
children
Hitesh Prajapati
Abstract
Urinary tract infections (UTI) are a common problem in childhood. The
clinical presentation is variable depending on age and whether there is
pyelonephritis or cystitis. UTI are diagnosed by culturing an appropri-
ately collected urine sample. Most children with UTI can be managed
safely with oral antibiotics irrespective of whether they have cystitis or
pyelonephritis. Following a single UTI a significant proportion of chil-
dren will develop recurrent UTI and many of these children will have
identifiable risk factors. Treating children with recurrent UTI with
repeated courses of antibiotics or long term prophylactic antibiotics
puts patients at risk of infections with multi-resistant organisms.
Furthermore recurrent UTI are also associated with the risk of renal
parenchymal damage with long term health implications. It is therefore
essential that management of children with UTI focuses not only on
early diagnosis and treatment but also on UTI prevention.
Keywords antibiotics; children; cystitis; pyelonephritis; urinary tract
infection
Introduction
Urinary tract infections (UTI) are a common problem in child-
hood. The clinical presentation is variable depending on age and
whether there is pyelonephritis (upper UTI) or cystitis (lower
UTI). Children and young people can become significantly un-
well with UTI especially infants and those with pyelonephritis.
An important complication of UTI is renal parenchymal damage
or renal scarring. A significant proportion of children that have
suffered with a single UTI will develop recurrent UTI. This is
often, but not always, related to underlying urinary tract ab-
normalities. Children with recurrent UTI are at greater risk of
developing renal scars. Furthermore the current conservative
management strategies used in recurrent UTI including repeated
treatment courses of antibiotics or daily prophylactic antibiotics
can lead to antimicrobial resistance. It is therefore essential that
the management of children with UTI focuses not only on early
diagnosis and treatment but also on UTI prevention.
Epidemiology
Studies have suggested a pooled prevalence of UTI of 7% in in-
fants and children under 2 years of age presenting with fever.
The prevalence appears to be greater in males under 3 months of
age particularly if they are uncircumcised. As children get older,
Hitesh Prajapati BMedSci (hons) MBChB MSc MRCPCH is a Consultant
Paediatric Nephrologist at Leeds General Infirmary, Leeds, UK.
Conflict of interest: None declared.
PAEDIATRICS AND CHILD HEALTH 28:7
there is an increasing female preponderance for UTI although the
overall frequency reduces.
Definition
UTI are defined as a pure growth of bacteria (104e105 colony
forming units/ml) in an appropriately collected urine sample from a
child or young person with clinical symptoms consistent with a UTI.
Pathogenesis
Escherichia coli (E. coli) is the most common uropathogenic or-
ganism accounting for approximately 80% of UTI. Other Gram
negative organisms causing UTI in children include Proteus spp,
Klebsiella spp and Enterobacter spp. UTI with Gram positive or-
ganisms are less common and often associated with
catheterisation.
The pathological organisms seen in UTI are commonly found
in the gastrointestinal tract and this supports the hypothesis that
UTI result from these bacteria ascending into the bladder and
urinary tract. Once bacteria are within the bladder they appear to
be able to adhere to the bladder epithelium (urothelium) ulti-
mately causing an inflammatory response and infection. The
infection can spread to the kidneys especially if there is under-
lying vesicoureteric reflux.
Between 12 and 30% of children that have suffered with a
single UTI will develop recurrent infections. Whilst bacteria
ascending into the bladder and causing UTI seems plausible for a
single UTI, this mechanism seems a less convincing pathological
process in those suffering from recurrent infections. There are
recognised risk factors for recurrent UTI (Table 1) including
structural abnormalities like vesicoureteric reflux. Interestingly,
children with similar structural abnormalities have a variable
propensity to developing recurrent UTI and there are some
children with an apparently normal urinary tract and no identi-
fiable risk factors that suffer with recurrent infections. These
observations would suggest that there are additional factors that
predispose some children to recurrent UTI. There is increasing
interest into the role of urothelium and the possibility that it has
an innate immune function in addition to its barrier function. The
molecular level interaction between urothelium and bacterial
pathogens may well be a contributing factor to the recurrent
infections seen in some children and young people.
Presentation
A thorough clinical assessment is required to identify the clinical
signs and symptoms of UTI (Table 2) as well as any potential risk
factors (Table 1). Diagnosis in infants can be particularly difficult
as the signs and symptoms are non-specific. Making a diagnosis of
UTI in this age group requires a high index of clinical suspicion.
In older children symptoms and signs may help localise the
infection. Children with cystitis are usually afebrile, have
suprapubic pain/discomfort, dysuria, frequency and inconti-
nence, whereas those with pyelonephritis tend to have fever, loin
pain/tenderness, rigors and generalised systemic upset.
Diagnosis
Diagnosis of UTI is made by culture of an appropriately collected
urine sample. Whilst obtaining a urine sample for culture is
318 Ó 2018 Elsevier Ltd. All rights reserved.
 SYMPOSIUM: NEPHROLOGY

essential to making the diagnosis and guiding antibiotic therapy,

Risk factors for UTI in children obtaining a sample should not delay treatment in those children
that are clinically unwell or septic. In older children that are toilet
Age less than 1 year trained, a clean catch urine is the preferred method for obtaining
Uncircumcised males a urine sample. Obtaining a clean catch urine in infants and
Constipation younger children in a busy emergency department or paediatric
Poor fluid intake assessment unit can be stressful for parents, time consuming and
Structural abnormalities e.g. vesicoureteric reflux, obstructive lead to delays in administration of appropriate treatment. In
uropathy many paediatric centres urine samples in infants are obtained by
Dysfunctional voiding pattern urethral catheterisation. Catheterisation requires trained staff
Poor toilet hygiene and sterile equipment. The procedure can introduce infection or
History of UTI cause urethral trauma so its routine use requires careful
consideration.
Table 1

Clinical signs and symptoms in children with a UTI

Signs and symptoms

Poor feeding

Faltering growth
< 3 months
Irritability

Jaundice

Irritability

3 months – 3
Lethargy and Abdominal pain
years Fever Haematuria Voming
malaise Inconnence

Abdominal pain

Loin tenderness

>3 years Inconnence

Frequency

Dysuria

Table 2

PAEDIATRICS AND CHILD HEALTH 28:7 319 Ó 2018 Elsevier Ltd. All rights reserved.
 SYMPOSIUM: NEPHROLOGY
Suprapubic aspiration is another invasive technique for
obtaining urine samples in infants although it appears to be
utilised less often. This may be due to reduced confidence of
paediatric trainees with suprapubic aspiration or due to the
recommendation that the procedure is carried out with ultra-
sound guidance, a facility that may not be available in all pae-
diatric and emergency departments.
Some advocate the use of urinary bags or pads to obtain
samples in infants and younger children. The diagnostic accuracy
of these samples is unreliable and can lead to incorrect diagnosis,
unnecessary treatment with antibiotics and subject children to
radiological investigations that they do not require. Ultimately
the method used for collecting urine samples in infants and
younger children must balance the clinical state of the child with
the advantages and disadvantages of each collection method,
whilst taking a pragmatic approach depending on the availability
of equipment and the training of local staff.
Urine culture is the gold standard for diagnosing UTI in chil-
dren and young people. In older children it is possible to un-
dertake preliminary bedside testing with urine dipsticks. Urine
dipsticks detect the presence of leucocyte esterase and nitrites.
Leucocyte esterase is produced by neutrophils so a positive
dipstick for leucocyte esterase indicates pyuria. Nitrites are pro-
duced from the breakdown of urinary nitrates by bacteria. A
bladder incubation period of approximately 4 hours is required
for the production of nitrites so urine dipsticks are not a suitable
test in infants and younger children that generally void
frequently.
The National Institute for Health and Clinical Excellence
(NICE) guidelines for UTI in children advocates the use of urgent
urine microscopy for diagnosing UTI in infants and younger
children. In practice, urgent microscopy is not available in all
centres and when it is, waiting for microscopy results can delay
antibiotic treatment. In departments where results can be made
available promptly, urine microscopy can be a useful diagnostic
tool. Otherwise the diagnosis of UTI in infants and younger
children is dependent on clinical assessment, absence of another
explanation for symptoms and the use of urine dipsticks
accepting that they are not as reliable in this age group.
Investigations that are not essential for diagnosing UTI but
may be useful clinically include white cell count, CRP, urea and
electrolytes and blood cultures. In neonates and infants UTI can
lead to meningitis and if this is suspected, lumbar puncture will
be required in addition to the above tests.
Imaging
Depending on the clinical presentation, it may be useful to un-
dertake further investigations to look for risk factors and com-
plications of UTI. Several guidelines have been published which
provide recommendations for imaging children with UTI.
Ultrasound scan
Acute ultrasound scans can be helpful to detect pyelonephritis
but they are not necessary routinely. Ultrasound will detect
structural abnormalities like duplex collecting systems, hydro-
nephrosis and ureteric dilatation which may point towards a
diagnosis of vesicoureteric reflux. Ultrasound can also be helpful
to assess the bladder and importantly, bladder emptying.
PAEDIATRICS AND CHILD HEALTH 28:7
Dimercaptosuccinic acid (DMSA) scan
DMSA scans are usually conducted no sooner than 3 months
after a UTI. DMSA scans are used to look for renal parenchymal
defects/scarring which are a recognised complication of UTI.
There are many that argue that the defects seen on DMSA scan
may not be scars but rather areas of renal dysplasia that occurred
during embryogenesis. In some situations this may well be the
case but repeat DMSA scans in children with recurrent UTI that
show progressive scarring, support the fact that UTI can cause
scarring.
Micturating cystourethrogram (MCUG)
MCUG is invasive and difficult to undertake in children. The
need for MCUG should be guided by the child’s clinical course as
well as the findings of the ultrasound scan  the DMSA scan.
MCUG may demonstrate bladder abnormalities and/or bladder
outlet obstruction. Any male presenting with a UTI that is found
to have bilateral renal dilatation on ultrasound scan must un-
dergo an MCUG to look for posterior urethral valve. The MCUG
may also identify bilateral or unilateral vesicoureteric reflux.
Minor degrees of vesicoureteric reflux can be managed conser-
vatively but surgical intervention is often required in those with
severe vesicoureteric reflux and recurrent UTI (see below).
Magnetic resonance imaging (MRI) scan
Constipation and day and night time wetting are common in
children. If there is a history of significant bowel and/or bladder
dysfunction or if these symptoms have been refractory to usual
conservative management, consider a spinal MRI. Although a
rare diagnosis, neuropathic bladder secondary to spinal dysra-
phism or closed neural tube defects may present with UTI. The
other indication for spinal MRI is if the MCUG demonstrates a
thick walled, trabeculated bladder without an underlying
obstructive cause suggesting a possible neuropathic bladder.
Management
Children and young people with suspected UTI should undergo a
careful and thorough clinical assessment. Patients that are septic
or clinically unwell should receive appropriate resuscitation and
emergency treatment followed by prompt administration of an-
tibiotics. In children that are clinically stable a urine sample
should be obtained and treatment initiated as outlined in
Figure 1. Unless the child is septic or clinically unwell, where a
delay in antimicrobial treatment would be detrimental, a urine
sample should always be sent for culture prior to commencing
antibiotics. The choice of antibiotic will depend on local bacterial
resistance patterns. Antibiotic therapy should be rationalised
with urine culture and sensitivity results.
Febrile infants under the age of 3 months are usually managed
with broad spectrum intravenous antibiotics after a full septic
screen.
Data suggest that there is no difference in time to resolution of
symptoms and incidence of renal scarring in older infants and
children with febrile UTI that are treated with oral antibiotics
alone versus those treated initially with parenteral antibiotics
followed by oral antibiotics. Therefore older infants and children
with suspected pyelonephritis can be managed safely with oral
antibiotics for 7e10 days. Shorter courses of antibiotics have
320 Ó 2018 Elsevier Ltd. All rights reserved.
 SYMPOSIUM: NEPHROLOGY
Obtain a urine sample if
there is a clinical
suspicion of UTI
Child over 2 years of age
Urine dipstick
Negative for nitrites and
Negative for nitrites and
positive for leucocyte
leucocyte esterase
esterase
Send urine for culture and
Unlikely UTI. Do not
commence antibiotics
commence antibiotics or
only if strong clinical
send urine for culture
suspicion of UTI
Figure 1 Diagnostic algorithm for UTI.
been shown to be equally efficacious to longer courses of anti-
biotics in children with cystitis. Therefore older infants and
children with cystitis can be managed with 3 days of appropriate
oral antibiotics.
Parenteral antibiotics may be required in patients who are
septic, unable to tolerate oral antibiotics or those infected with
multi-resistant organisms where there is no oral antibiotic op-
tion. Patients with underlying urinary tract abnormalities, those
who already have significant scarring or underlying chronic
kidney disease and children who are immunocompromised or
immunosuppressed may also benefit from parenteral antibiotics.
Complications
The most significant complication of UTI is renal scarring. There
are recognised risk factors for renal scarring which are outlined
in Table 3. The overall incidence of renal scarring in children
after a first UTI is reported to be up to 15%. Renal scarring in
these children was found to be more common in those with
vesicoureteric reflux but was seen in children without ves-
icoureteric reflux.
Renal scarring can lead to proteinuria, hypertension and if
severe, chronic renal impairment. End stage renal disease
attributed solely to scarring from UTI is uncommon and when
seen is usually in association with abnormalities like bilateral
high grade vesicoureteric reflux. There are limited data available
for the long term prognosis of minor renal scarring. Most ne-
phrologists would advocate that all children with renal scarring,
PAEDIATRICS AND CHILD HEALTH 28:7
Child <2 years of age
Assess clinically for signs and symptoms
Request urgent urine microscopy if
results can be available promptlly
If microscopy not available and no other
identifiable diagnosis/explanation for
symptoms treat as UTI
Positive for nitrites,
Positive for nitrites and
negative for leucocyte
leucocyte esterase
esterase
Send urine for culture
and commence
antibiotics
even those with minor scarring, are followed up long term to
monitor for the development of hypertension or proteinuria.
Renal scarring in children and young people with chronic
kidney disease secondary to congenital abnormalities of kidney
and urinary tract can have more significant implications for renal
health. Loss of what limited functional renal tissue these patients
have can lead to progression of chronic kidney disease, loss of
residual renal function and the need for renal replacement ther-
apy with its associated sequelae. UTI are also a problem in
children who have received a renal transplant. Damage to the
transplant kidney in these immunosuppressed patients can have
a significant impact on overall graft survival.
Children and young people with recurrent UTI are managed
with either repeated treatment courses of antibiotics or often
prophylactic antibiotics to try and prevent infections. Both of
these antibiotic strategies in children with recurrent UTI are
likely to add to the burden of evolving bacterial resistance and
Risk for renal scarring in children with UTI
Vesicoureteric reflux especially grade IV and V
Infection with organisms other than E. Coli
Fever >39  C
Abnormal urinary tract ultrasound scan
CRP >40 mg/L
Delay in commencing antibiotic treatment
Table 3
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 SYMPOSIUM: NEPHROLOGY

the increasing difficulty of managing patients with infections. It is antibiotics are likely to increase the likelihood of infections with
therefore essential that UTI are accurately diagnosed and anti- resistant organisms. The use of prophylactic antibiotics is
biotic treatment administered only when required. It is also therefore not without significant risk and their use should only be
important to employ preventative strategies for UTI in all patients considered in children and young people with recurrent symp-
with recurrent UTI. tomatic, culture proven infections or children and young people
with chronic kidney disease or renal transplants that are at high
Prevention risk from the complications of recurrent UTI. If prophylaxis is
commenced, it should be reviewed 6 monthly and stopped if
A significant proportion of children will develop recurrent UTI.
there have been no UTI.
Preventative strategies are directed towards any identifiable risk
factors.
Dietary modification: although cranberry juice and probiotics
have been suggested as possible ways to reduce the frequency of
Fluid intake: poor fluid intake is not unusual in children with
UTI in children, there is no conclusive evidence to support that
recurrent UTI. Encouraging adequate fluid intake can help reduce
they have a beneficial effect.
the frequency of UTI. It may also help address any underlying
bladder dysfunction by improving bladder capacity and fre-
Surgical intervention: despite all the above conservative mea-
quency of voiding. Suggested estimates for adequate fluid intake
sures some children continue to be troubled by recurrent UTI. If
based on figures quoted in the NICE guidelines for management
there is an underlying structural abnormality like vesicoureteric
of bedwetting in under 19s and the NICE guidelines for con-
reflux, patients may benefit from surgical intervention with
stipation in children and young people are:
either endoscopic correction of reflux or in selected cases ureteric
 4e8 years 1000e1400 ml
re-implantation. Circumcision should also be considered in
 9e13 years 1600e2400 ml
males, especially infants with recurrent UTI.
 14e18 years 1800e2000 ml
Recurrent UTI is commonly seen in children with dysfunc-
tional bladders secondary to posterior urethral valve or neuro-
Constipation: can predispose children to UTI and should be
pathic bladder. The infections are thought in part to be related to
treated with laxatives in conjunction with adequate fluid intake
incomplete bladder emptying. In the short term these children
and dietary modification. NICE guidelines are available with a
can be managed with intermittent urethral catheterisation. Long
suggested approach to managing constipation.
term they will require more extensive surgical intervention to
improve bladder emptying. The exact surgical intervention
Dysfunctional voiding: many children presenting with recurrent
employed depends on the child’s individual circumstances and
UTI have dysfunctional voiding patterns. Clues in the history
may include an indwelling suprapubic catheter or creation of a
include children with day or night time wetting, hesitancy, poor
Mitrofanoff stoma which can be used to catheterise the bladder
urinary stream, urinary frequency (>8 voids per day), urgency,
and ensure adequate emptying.
infrequent voiding (<3 times per day) or post micturition drib-
bling (suggesting incomplete bladder emptying). All children and
Conclusions
young people should be advised to ensure adequate fluid intake
which will naturally encourage more frequent voiding. They UTI are a common infection in children and young people. Pre-
should also be advised to void regularly (between 5 and 7 times sentation of UTI can be non-specific especially in infants and
per day). If there is a post void residual volume identified on younger children. Many children will suffer with recurrent UTI
ultrasound scan, those that are able to comply should be advised which can be complicated by renal scarring. Clinical assessment
to practice double voiding. of children with UTI should include a review of the risk factors
A small proportion of children may require referral to specialist for recurrent UTI. Management should not only include treat-
services for a more in depth bladder assessment. Useful informa- ment with antibiotics but also address the preventative strategies
tion can be gathered from non-invasive bladder assessment for recurrent UTI. A
including pre and post micturition bladder scans and uro-
flowometry. The management of some children may be improved
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