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South Australian Paediatric Clinical Practice Guidelines 

Urinary Tract Infection in Children 
  Department for Health and Wellbeing, Government of South Australia. All rights reserved. 

Note:
This guideline provides advice of a general nature.  This statewide guideline has been prepared to promote and 
facilitate standardisation and consistency of practice, using a multidisciplinary approach.  The guideline is based 
on a review of published evidence and expert opinion.  
Information in this statewide guideline is current at the time of publication.  
SA Health does not accept responsibility for the quality or accuracy of material on websites linked from this site 
and does not sponsor, approve or endorse materials on such links. 
Health practitioners in the South Australian public health sector are expected to review specific details of each 
patient and professionally assess the applicability of the relevant guideline to that clinical situation. 
If for good clinical reasons, a decision is made to depart from the guideline, the responsible clinician must 
document in the patient s medical record, the decision made, by whom, and detailed reasons for the departure 
from the guideline. 
This statewide guideline does not address all the elements of clinical practice and assumes that the individual 
clinicians are responsible for discussing care with consumers in an environment that is culturally appropriate and 
which enables respectful confidential discussion. This includes: 

  The use of interpreter services where necessary,
  Advising consumers of their choice and ensuring informed consent is obtained,
  Providing care within scope of practice, meeting all legislative requirements and maintaining standards

of professional conduct, and
  Documenting all care in accordance with mandatory and local requirements

Explanation of the aboriginal artwork: 
The aboriginal artwork used symbolises the connection to country and the circle shape shows the strong relationships amongst families and the aboriginal culture. 
The horse shoe shape design shown in front of the generic statement symbolises a woman and those enclosing a smaller horse shoe shape depicts a pregnant 
woman. The smaller horse shoe shape in this instance represents the unborn child. The artwork shown before the specific statements within the document 
symbolises a footprint and demonstrates the need to move forward together in unison. 

    

 

 

 

 

 
 
 
 

The term  Aboriginal  is used to refer to people who identify as Aboriginal, Torres Strait Islanders, or both Aboriginal and Torres Strait 
Islander.  This is done because the people indigenous to South Australia are Aboriginal and we respect that many Aboriginal people prefer the 
term  Aboriginal .  We also acknowledge and respect that many Aboriginal South Australians prefer to be known by their specific language 
group(s). 

 Cultural safety enhances clinical safety. 

To secure the best health outcomes, clinicians must provide a culturally safe health care 
experience for Aboriginal children, young people and their families. Aboriginal children 
are born into strong kinship structures where roles and responsibilities are integral and 
woven into the social fabric of Aboriginal societies. 

Australian Aboriginal culture is the oldest living culture in the world, yet Aboriginal 
people currently experience the poorest health outcomes when compared to non-
Aboriginal Australians. 

It remains a national disgrace that Australia has one of the highest youth suicide rates in 
the world.  The over representation of Aboriginal children and young people in out of 
home care and juvenile detention and justice system is intolerable. 

The cumulative effects of forced removal of Aboriginal children, poverty, exposure to 
violence, historical and transgenerational trauma, the ongoing effects of past and present 
systemic racism, culturally unsafe and discriminatory health services are all major 
contributors to the disparities in Aboriginal health outcomes. 

Clinicians can secure positive long term health and wellbeing outcomes by making well 
informed clinical decisions based on cultural considerations. 



 Urinary Tract Infection (UTI) in Children 
 

 

 
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Purpose and Scope of PCPG 
The Urinary Tract Infection (UTI) in Children Paediatric Clinical Practice Guideline (PCPG) 
main focus is on the management of bacterial UTI and is primarily aimed at medical staff 
working in any of the primary care, local, regional, general or tertiary hospitals. It may 
however assist the care provided by other clinicians such as nurses.  

The information is current at the time of publication and provides a minimum standard for the 
assessment (including investigations) and management of UTI in children; it does not replace 
or remove clinical judgement or the professional care and duty necessary for each specific 
case. 

 

Table of Contents 
Purpose and Scope of PCPG 2 

Important points 3 

Abbreviations 3 

Definition 4 

Flowchart 5 

Summary of Practice Recommendations 6 

Assessment 6 

Examination 6 

Diagnosis of UTI 7 

Urine collection methods 7 

Investigations for unwell children presenting to Emergency Department 8 

Other inpatient investigations 8 

Interpretations of results 8 

Urine dipstick 9 

Urine culture 9 

Treatment of UTI 10 

Summary of post UTI renal tract imaging 13 

Criteria for transfer 14 

Criteria for discharge 14 

Indications for consideration of referral to Paediatric urology clinic 14 

Indications for consideration of referral to Paediatric renal clinic 14 

References 15 

Acknowledgements 17 

Document Ownership &amp; History 17 

Appendices 18 

 



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Important points 
&gt; Urinary tract infections (UTIs) in childhood are common and can be potentially serious in 

the first few years of life.  
&gt; An estimated 2% of boys and 8% of girls will experience a UTI by seven years of age.  
&gt; The diagnosis of UTI should be considered in infants and young children with non-specific 

symptoms and in all febrile infants and young children especially those without focus.  
&gt; Children and infants who are seriously unwell require IV antibiotics. 
&gt; Infants under 3 months with suspected UTI should be considered for admission and IV 

antibiotics, even if not seriously unwell. 
&gt; Urine samples should be collected prior to starting antibiotics unless the child is seriously 

unwell and requires immediate IV therapy. 
&gt; Microscopy of uncontaminated urine which shows pyuria +/- bacteriuria followed by 

culture is the gold standard in diagnosis of UTI.  
&gt; Admitted children with UTI who presented severely unwell or with atypical UTI should 

have a renal ultrasound prior to discharge to exclude renal tract obstruction or 
abnormality.  

&gt; Children with recurrent or atypical UTI require further investigation of their renal tract.  
&gt; Post-treatment urine culture to confirm resolution of infection for asymptomatic children is 

not routinely indicated. 

Abbreviations 

CCU Clean catch urine specimen  

CFU Colony forming unit  

CRP C reactive protein  

CSU Catheter specimen of urine  

DMSA Dimercaptosuccinic acid 

EUC Electrolytes, urea and creatinine 

E coli Escherichia coli  

FBC Full blood count 

IV Intravenous 

MCU Micturating cystourethrogram 

MSU Mid-stream urine specimen 

PCR  Polymerase chain reaction  

SPA Suprapubic aspirate  

STI Sexually transmitted infection 

UTI  Urinary tract infection 

UTIs Urinary tract infections 

VUR Vesicoureteric reflux 

 

  



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Definition 
Urinary tract infection (UTI) refers to infection in the bladder (cystitis), or kidneys and ureters 
(pyelonephritis). UTI in children is commonly acute pyelonephritis; it is difficult to distinguish 
pyelonephritis from cystitis, particularly in infants.  

In older children, if the child has bacteriuria and localising symptoms (such as dysuria, 
frequency, urgency or lower abdominal discomfort), and does not have fever (38 C or higher) 
or loin pain or tenderness, treat as acute cystitis. If the child has bacteriuria and either fever 
(38 C or higher) or loin pain or tenderness, treat as acute pyelonephritis. 

Pyelonephritis is considered non-severe if the child does not have systemic features (e.g. 
tachycardia, nausea, vomiting), or sepsis or septic shock. Pyelonephritis is considered severe 
in the presence of these features.  

Pyuria and/or bacteriuria is the presence of white cells and/or bacteria in the urine with or 
without urinary tract infection (see Interpretations of results). 

Atypical UTI includes any of the following: 

? Aged less than 3 months  
? Any seriously ill child or septicaemia 
? History of poor urine flow or history of abnormal urinary tract on antenatal ultrasound  
? Abdominal or bladder mass palpable  
? Raised creatinine 
? Failure to respond to suitable antibiotics within 48 hours  
? Infection with uncommon organisms, i.e. non E. coli organisms. 

Recurrent UTI is defined as children who have either:   

? Two or more UTIs with acute pyelonephritis, or 
? One episode of acute pyelonephritis and one or more UTI with cystitis, or 
? Three or more UTIs with cystitis.  
 

  





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Flowchart 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  

Suspected UTI 
OR 

High risk of UTI 
(see flags of increased risk of UTI) 

Urine collection 
(See Urine collection methods) 

Immediate IV therapy 
(See treatment of UTI) 

Confirmed UTI or suspected on 
urine analysis 

(See Interpretations of results)  

Investigations 
(See Table, Investigations for 
unwell children presenting to 

Emergency Department)  

Treatment 
(See Table, Treatment of UTI) 

Follow up investigations 
(See Table, Investigations for 

children after diagnosis of UTI) 

Follow up  
- Indications for referral 
- Indications for antibiotic prophylaxis                        

No sign of toxicity or sepsis 
 

Seriously unwell child 
(sign of toxicity or sepsis) 

See  
Sepsis in 
Children 
Guideline 







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Summary of Practice Recommendations 

Assessment 
Diagnosing a UTI in young children can be challenging as symptoms can be non-specific.  
The clinical features on history are variable and age-dependent:  

Symptoms that might be present on presentation  

&lt; 3 months 3 months   3 years &gt; 3 years 

Fever 
Vomiting 
Lethargy 
Irritability 
Poor feeding 
Failure to thrive 
Jaundice 
Haematuria 
Offensive urine 

Fever 
Abdominal pain 
Loin tenderness  
Vomiting  
Poor feeding  
Lethargy  
Irritability  
Haematuria  
Offensive urine  
Failure to thrive  

Urinary frequency  
Dysuria  
Dysfunctional voiding  
Changes to continence  
Abdominal pain  
Loin tenderness  
Fever  
Malaise  
Vomiting  
Haematuria  
Offensive urine  
Cloudy urine  

 
History should also include specific flags of increased risk of UTI such as: 

&gt; Congenital genitourinary tract malformations (i.e. ask about antenatal ultrasound) 

&gt; Spina bifida or other causes of neurogenic bladder  

&gt; Phimosis or labial adhesion 

&gt; Bladder or bowel dysfunction  

&gt; Previous history of recurrent UTIs 

&gt; Abnormal urine stream/ flow i.e. dribbling or straining (might suggest obstruction) 

&gt; Surgical alterations to urinary tract.  

Examination 

&gt; No physical sign is pathognomonic for a UTI 

&gt; Examination may be normal (except fever)  

&gt; Assess for sepsis (refer to the  Sepsis  guideline under Paediatric Clinical Guidelines 
available at https://extapps2.sahealth.sa.gov.au/PracticeGuidelines/)  

&gt; Lower abdominal or loin tenderness may be present 

&gt; Non-specific findings include dehydration and lethargy 

&gt; Abdominal examination may identify a palpable mass 

&gt; Examine external genitalia to identify a genitourinary abnormality predisposing to UTI 

&gt; Lower limb neurological examination should be considered if impaired bladder emptying  

&gt; Don t forget to check blood pressure.  

  




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&gt; Refer to the  Sepsis  guideline under Paediatric Clinical Guidelines available at 
https://extapps2.sahealth.sa.gov.au/PracticeGuidelines/ for a child presenting with toxic 
features including tachypnoea, increased work of breathing, grunt, weak cry, 
marked/persistent tachycardia, moderate to severe dehydration.  

&gt; Refer to the  Fever  guideline under Paediatric Clinical Guidelines available at 
https://extapps2.sahealth.sa.gov.au/PracticeGuidelines/ for the assessment of children 
with a fever ?38o C without localising signs. In general, the younger the infant or child is, 
the lower the threshold for urine screening. 

Diagnosis of UTI 

Microscopy of uncontaminated urine which shows pyuria +/- bacteriuria followed by 
culture is the gold standard in diagnosis of UTI.  

Urine collection methods 

 

  

Collection method  Utility  Notes  

Supra-pubic 
bladder aspiration  
(SPA)  

  age &lt; 6 months and toxic  
  phimosis or labial adhesion 

  invasive  

  gold standard as lowest 
contamination rate  

  success rate varies (23 - 90%) 
depending on operator, use of 
ultrasound and the presence 
of at least 20mL of urine  

  ultrasound significantly 
increases success rate  

Urethral 
catheterisation 
(CSU)  

 in-out catheter   

  age &gt; 6 months and toxic  

  age &lt; 6 months and toxic with 
failed SPA  

  where CCU/MSU not  
possible/failed 

  invasive 

  low contamination rate  

  highest success rate  

  risk of iatrogenic infection 

Clean catch 
specimen (CCU)  

  non-urgent collection and 
unable to void on request  

(A randomised controlled trial 
showed suprapubic stimulation 
hastened non-invasive urine 
collection (CCU) from infants)  

  non-invasive   

  high false positive rate if poor 
collection technique 

Midstream urine 
(MSU)  

  non-urgent collection and able 
to void on request  

  preferred method for toilet-
trained children who can void 
on request  

Bag specimens  / 
cotton wool balls 
specimens  

  not recommended, however 
UTI can be excluded in 
children based on negative 
urinalysis 

  high contamination rate so not 
recommended for UTI 
diagnosis 





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Investigations for unwell children presenting to Emergency Department 

Birth to 6 weeks 6 weeks to 3 months &gt; 3 months 
Toilet trained 
children 

FBC, CRP, EUC, 
Blood Culture 

Sterile site PCR 

Urine (SPA) 

Lumbar puncture 

FBC, CRP, EUC, 
Blood Culture. 

Sterile site PCR  

Urine (SPA or in  
out catheter)  

Lumbar puncture if 
toxic signs present 

FBC, CRP, EUC, 
Blood Culture and 
sterile site PCR if 
clinically indicated 

Urine (in  out 
catheter or clean 
catch, consider 
SPA if ? 6 months)  

Consider LP if 
clinically indicated 

FBC, CRP, EUC, 
Blood Culture and 
sterile site PCR if 
clinically indicated 

Clean catch or 
mid-stream urine  

In   out catheter if 
unwell and delay in 
obtaining a clean 
catch urine  

Other inpatient investigations 
Consider imaging (kidney and bladder ultrasound) for the following children:  

  No response to 48 hours of appropriate antibiotic therapy  
  Severely unwell/septic 
  Renal impairment 
  Boys ? 3 months to exclude obstruction (i.e. posterior urethral valves) 
  Upper renal tract features  
  Recurrent urinary tract infections (to identify/exclude a structural abnormality) if they 

did not have previous ultrasound. 
Consider sexually transmitted infection (STI) screening including Gonorrhoea and Chlamydia 
PCR testing on urine where appropriate. 

Interpretations of results 

Urinalysis  
analysis result Implications Management Further testing 

Leucocyte esterase 
positive and Nitrite 
positive 

Consistent with 
UTI 

Commence 
antibiotics  

Send urine for MCS 

Leucocyte esterase 
positive and Nitrite 
negative 

Treat as UTI if 
clinically 
indicated  

Consider 
antibiotics 

Send urine for MCS and 
consider infection outside the 
urinary tract 

Leucocyte esterase 
negative and Nitrite 
positive 

Treat as UTI if 
clinically 
indicated 

Consider 
antibiotics 

Send for MCS  

Leucocyte esterase 
negative and Nitrite 
negative 

Do not treat as 
UTI 

Antibiotics 
for UTI 
should not 
be started  

Unlikely to be a UTI, 
consider other causes of 
illness. MCS is usually still 
sent in non-toilet trained 
children.   



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Urine dipstick 
Dipstick analysis is less reliable in neonates and infants with the risk of falsely negative 
testing. It is recommended to send urine sample for culture for neonates and infants even if 
urine analysis is negative. 

Not all urinary organisms produce nitrites, so the absence of nitrites does not exclude UTI.  
Urine must be present in the bladder for enough time for the reaction to occur   non-toilet 
trained children may have a false negative due to more frequent bladder emptying.   
Leucocytes may come from other anatomically related areas, e.g. appendicitis. Pyuria 
(leucocytes) can occur with other febrile illnesses, so pyuria alone on dipstick/microscopy 
does not confirm UTI. 
Pyuria (with no epithelial cells) and bacteria seen on microscopy are suggestive of UTI, but a 
positive culture is required to confirm the diagnosis. 
Epithelial cells (squames) suggest skin contamination and a poorly collected sample; consider 
recollection if clinically indicated. 
The presence of blood or protein on dipstick testing is not a reliable marker of UTI. 

Urine culture 

  Growth of a single organism at &gt; 108 CFU/litre (&gt; 105 CFU/ml) from any collection 
method suggests infection. 

  Growth of a single organism at lower counts of 106-8 CFU/litre (&gt; 103-5 CFU/ml) from 
catheter urine suggests infection, and from clean catch or MSU may indicate early 
infection. 

  Growth of any amount from SPA suggests infection. 



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Treatment of UTI 

Birth* to 3 months of age Over 3 months of age  

Most infants under 3 
months should be admitted 
for initial IV antibiotics 

Well Unwell but not toxic. Tolerating oral intake. 

Unwell and not tolerating 
oral intake/vomiting/ 
toxic/sepsis 

IV antibiotics:  
Gentamicin &amp; Amoxicillin 

 

If Gentamicin is 
contraindicated use 
Cefotaxime as 
monotherapy  

 

*For neonates, including 
those less than 44 weeks 
corrected age, refer to the 
specific antibiotic guideline 
on the South Australian 
Neonatal Medication 
Guidelines for appropriate 
dosing. DO NOT use the 
antibiotic doses listed in this 
table for this patient group. 

Discharge on empiric oral 
antibiotics: 

**Cefalexin OR  
Amoxicillin-Clavulanate 
OR  

**Nitrofurantoin (ONLY 
FOR CYSTITIS) 

OR 

Trimethoprim OR 
Trimethroprim + 
Sulfamethoxazole 

with GP follow up in 48 
hours. 

**For paediatric antibiotic 
therapy, refer to the 
WCHN Paediatric 
Antibacterial Quick 
Reference Card 
(Appendix 1.) 

Consider one dose of IM 
Gentamicin or 
Ceftriaxone.  

Discharge home on oral 
antibiotics: 

**Cefalexin OR  
Amoxicillin-Clavulanate 
OR 

**Nitrofurantoin (ONLY 
FOR CYSTITIS) 

OR 

Trimethoprim OR 
Trimethroprim + 
Sulfamethoxazole 

with GP follow up in 48 
hours. 

 

Urine samples should be 
collected prior to starting 
antibiotics unless the child 
is seriously unwell and 
requires immediate IV 
therapy. 

IV antibiotics: Gentamicin &amp; 
Amoxicillin. 

Use Ceftriaxone as 
monotherapy if Gentamicin 
is contraindicated. 

Modify antibiotics 
depending on culture 
sensitivity. Switch to oral 
therapy once the child is 
clinically stable and can 
tolerate oral therapy.  

GP and Paediatric follow 
up.  

Duration of antibiotic 
treatment (IV or oral) 

Total duration of 3 days for cystitis depend on clinical response. 

Total duration of 7 - 10 days for pyelonephritis depend on clinical response. 

Resistant bacteria Consult Infectious Disease if ESBL-producing bacteria/multidrug resistant bacteria or 
if longer duration of treatment is required or in children hypersensitive or allergic to 
penicillin. 

Empirical therapy for severe 
pyelonephritis or UTI sepsis 
or children with UTI unable 
to tolerate oral intake  

Gentamicin 
  Term infants and children (1 month to 10 years of age): 

o 7.5 mg/kg intravenously once daily. Use ideal body weight. 
o Initial maximum dose 320 mg 

  10 to 18 years of age: 
o 6 to 7 mg/kg intravenously once daily. Use ideal body weight. 
o Initial maximum dose 560 mg 

Plus 
Amoxicillin or Ampicillin 50 mg/kg up to 2 g intravenously, 6-hourly. 

If Gentamicin 
contraindicated 

Cefotaxime 50 mg/kg up to 1 g intravenously, 8-hourly (up to 2 g intravenously 8-
hourly for children with sepsis or requiring intensive care support) OR,  

Ceftriaxone (child 1 month or older) 50 mg/kg up to 1 g intravenously, daily (Use 50 
mg/kg up to 1 g, 12-hourly for children with sepsis or requiring intensive care 
support).  






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If penicillin allergy  Use Gentamicin as monotherapy and consult with Infectious Diseases.  

Oral antibiotic for treatment 
of acute cystitis and 
pyelonephritis in children 
tolerating oral therapy  

Choice of oral antibiotic is 
guided by urine culture 
sensitivity  

Cefalexin 12.5 mg/kg up to 500 mg orally, 6-hourly. 

OR 
Amoxicillin + Clavulanate orally,  

Infant younger than 2 months: 15+3.75 mg/kg, 8-hourly. 

Child 2 months or older: 22.5+3.2 mg/kg up to 875+125 mg,12-hourly. 

OR 
Trimethoprim + sulfamethoxazole (child 1 month or older) 4+20 mg/kg up to 
160+800 mg orally, 12-hourly. 

OR (if a suitable trimethoprim formulation is available) 

Trimethoprim 4 mg/kg up to 160 mg orally, 12-hourly, 

OR 
**Nitrofurantoin (ONLY FOR CYSTITIS) (child older than 1 month) 0.75mg   
1.75mg/kg up to 100mg orally, 6 hourly (consult with Infectious Diseases if risk of 
adverse effects) 

If culture and susceptibility 
testing indicate the 
pathogen is resistant to 
empirical oral therapy 

Do not modify therapy if symptoms are improving. 

If resistance to all the above 
drugs is confirmed, 
provided the pathogen is 
susceptible, suitable 
alternatives are: 

*Consult with Infectious 
Diseases 

Norfloxacin 10 mg/kg up to 400 mg orally, 12-hourly (if a suitable norfloxacin 
formulation is available), 

OR 

Ciprofloxacin 12.5 mg/kg up to 500 mg orally, 12-hourly (if a suitable ciprofloxacin 
formulation is available). 

Pseudomonas aeruginosa Infection with Pseudomonas aeruginosa can be associated with coexisting urological 
abnormalities. Treat children who have UTI caused by P. aeruginosa with 
Norfloxacin or Ciprofloxacin as above; however, a longer treatment duration is 
often required  seek Infectious Disease advice. 

Asymptomatic bacteriuria  Do not routinely screen for or treat asymptomatic bacteriuria in infants or children, 
except in some patients undergoing elective urological procedures. 

In children with indwelling 
urinary catheter 

In catheterised children, collect a specimen and contact the treating team. Catheters 
should only be removed on specialist advice. 

Bacterial colonisation of long-term catheters is common, and these children are often 
asymptomatic despite pyuria and bacteriuria. 

Empiric and/or prophylactic antibiotics should be decided on a case by case basis, 
ideally after discussion with the child s Paediatrician and where relevant, Infectious 
Disease physician or Surgical team. Improper use of antibiotics in this cohort may 
encourage the development of antibiotic resistance.  

Post treatment  Performance of post-treatment urine culture to confirm resolution of UTI for 
asymptomatic children is not routinely indicated. 




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Antibiotic prophylaxis 

Do not routinely give antibiotic prophylaxis to infants or children following the first episode of 
urinary tract infection (UTI). 

Antibiotic prophylaxis is not routinely used for cases of vesicoureteric reflux (VUR).  

Antibiotic prophylaxis for UTI in children increases the risk of infection with multidrug-resistant 
bacteria. 

Indications to consider antibiotic for UTI prophylaxis: 
1. Recurrent UTI, or  
2. Vesicoureteric reflux grades III to V, or 
3. If recommended by the child s nephrologist or urologist for other indications 
4. Short duration of prophylaxis prior to MCU. 

Antibiotic prophylaxis 

Cefalexin 12.5 mg/kg up to 250 mg orally, at night, OR 

Trimethoprim + sulfamethoxazole (child 1 month or older) 2+10 mg/kg up to 80+400 mg 
orally, at night, OR 

Trimethoprim 2 mg/kg up to 150 mg orally, at night (if a suitable trimethoprim formulation is 
available), OR 

Nitrofurantoin (child 1 month or older) 1 mg/kg up to 50 mg orally, at night (if a suitable 
Nitrofurantoin formulation is available). Risk of adverse effects with long-term use   consult 
with Infectious Diseases. 

Review the need for prophylaxis every 6 months 

Investigations for children after diagnosis of UTI 
Further investigation is dependent on type of UTI   typical vs. atypical, single episode vs. 
recurrent episodes. 

Children with atypical or recurrent UTIs require imaging of their renal tract. 

  



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Summary of post UTI renal tract imaging 
^Seek specialist advice first before arranging MCU or DMSA 
#See consideration for referral p. 14 

Age &lt; 6 months 

Test Ultrasound 
during 
episode 

Ultrasound  
6 weeks 
later 

^DMSA - 4 to 6 
months after the 
infection resolved 

^MCU 

 

Typical UTI No Yes No 
Consider if 
ultrasound abnormal  

#Atypical or 
recurrent UTI Yes No Yes 

Yes - delay at least 2 
weeks after the 
infection resolved 

Age 6 months to 3 years 

Test Ultrasound 
during episode 

Ultrasound 6 
weeks later 

^DMSA - 4 to 6 months after 
the infection resolved   

(large radiation exposure) 

Typical UTI No No No 

#Atypical UTI Yes No Yes 

#Recurrent UTI No Yes Yes 

MCU is not routinely indicated for this age group for either atypical or recurrent UTI but it may 
need to be considered if an atypical infection, abnormal ultrasound or family history of VUR 
(consider procedure sedation). 

Age &gt; 3 years 

Test Ultrasound 
during episode 

Ultrasound 6 
weeks later 

^DMSA - 4 to 6 months after 
the infection resolved   
(large radiation exposure) 

Typical UTI No No No 

#Atypical UTI Yes No No 

#Recurrent UTI No Yes Yes  

MCU is not routinely recommended for this age group for either atypical or recurrent UTI 
(consider procedure sedation). 
 



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Criteria for transfer 
Any child requiring care beyond the level of comfort of the treating hospital. Decision of 
transfer is to be discussed and accepted by the receiving team at the receiving hospital. 

Criteria for discharge 
1. Clinically stable 
2. Tolerating oral intake/oral antibiotic 

Plan for discharge 

1. Parent/carer to organise follow up with GP 
2. Provide discharge letter to parent/carer and to GP 
3. Organise referral to general paediatric clinic for children presenting with atypical or 

recurrent UTI 
4. Consider referral to Paediatric Urologist or Nephrologist if indicated 

Indications for consideration of referral to Paediatric urology clinic 
1. Urgent referral if there is evidence or suspicion of renal tract obstruction  
2. High grade vesicoureteric reflux  
3. Recurrent and atypical UTI  
4. Structural urological abnormality 
5. Suspected neurogenic bladder 

Indications for consideration of referral to Paediatric renal clinic 
1. Renal scarring 
2. Hypertension 
3. Persistent deranged renal function 

  



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References 
1. Therapeutic Guidelines. 2020. Approach to managing urinary tract infection in children. 

[ONLINE] Available at: https://tgldcdp.tg.org.au/viewTopic?topicfile=urinary-tract-infection-
children-approach&amp;guidelineName=Antibiotic&amp;topicNavigation=navigateTopic. [Accessed 9 
April 2020].  

2. South Australian Department for Health and Wellbeing (2020) Neonatal Medication 
Guidelines [ONLINE] Available at: 
https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/clinical+
resources/clinical+programs+and+practice+guidelines/womens+and+babies+health/neonatal
+medication+guidelines/neonatal+medication+guidelines [Accessed 9 April 2020].  

3. McTaggart, S, Danchin, MH, Ditchfield, M, Hewitt, IK, Kausman, JY, Kennedy, SE, Trinka, P 
&amp; Williams, G 2015, 'KHA-CARI guideline: Diagnosis and treatment of urinary tract infection 
in children', Nephrology, vol. 20, pp. 55 -60. https://doi.org/10.1111/nep.12349  

4. NICE. 2018. Clinical guideline [CG54]: Urinary tract infection in under 16s: diagnosis and 
management. [ONLINE] Available at: https://www.nice.org.uk/guidance/cg54. [Accessed 9 
April 2020].  

5. Government of Western Australia (2014) Diagnostic Imaging Pathways - Paediatric, Urinary 
Tract Infection. [ONLINE] Available at: 
http://www.imagingpathways.health.wa.gov.au/index.php/imaging-
pathways/paediatrics/urinary-tract-infection#pathway-home. [Accessed 9 April 2020].  

6. Perth Children's Hospital (2017) Urinary tract infection - investigations and follow up. 
[ONLINE] Available at: https://pch.health.wa.gov.au/For-health-professionals/Clinical-
Practice-Guidelines/Urinary-tract-infection-investigations. [Accessed 9 April 2020].  

7. Perth Children's Hospital (2017) Urinary tract infection. [ONLINE] Available at: 
https://pch.health.wa.gov.au/For-health-professionals/Emergency-Department-
Guidelines/Urinary-tract-infection. [Accessed 9 April 2020].  

8. The Sydney Children's Hospitals Network (2017) Urinary tract infection in children. [ONLINE] 
Available at: https://www.schn.health.nsw.gov.au/fact-sheets/urinary-tract-infection-in-
children. [Accessed 9 April 2020]. 

9. The Sydney Children's Hospitals Network (2018) Urinary Tract Infection (Typical) 
Identification and Management Practice Guideline: 2009-8038 v3. [ONLINE] Available at: 
https://www.google.com/url?sa=t&amp;rct=j&amp;q=&amp;esrc=s&amp;source=web&amp;cd=2&amp;ved=2ahUKEwi-
8MaGjenoAhXlzTgGHbA4CG4QFjABegQIARAB&amp;url=http%3A%2F%2Fwww.schn.health.ns
w.gov.au%2F_policies%2Fpdf%2F2009-8038.pdf&amp;usg=AOvVaw3wosB6uMgQz7_qqadi8t9n. 
[Accessed 9 April 2020].  

10. The Royal Children's Hospital Melbourne (2019) Urinary tract infection. [ONLINE] Available 
at: https://www.rch.org.au/clinicalguide/guideline_index/Urinary_tract_infection/. [Accessed 9 
April 2020]. 

11. Kaufman J, Temple-Smith M, Sanci L. Urinary tract infections in children: an overview of 
diagnosis and management. BMJ Paediatrics. Open 2019;3:e000487. doi:10.1136/ bmjpo-
2019-000487. 

12. L. Hua, R.J. Linke, H.A.P. Boucaut, S. Khurana., Micturating cystourethrogram as a tool for 
investigating UTI in children e An institutional audit.  [Online]. Journal of Pediatric Urology, 
2016: Volume 12, Issue 5, Pages 292.e1 292.e5. Available at: 
https://www.jpurol.com/article/S1477-5131(16)30015-8/fulltext [Accessed 9 April 2020]. 

13. Williams G, Craig JC. Long-term antibiotics for preventing recurrent urinary tract infection in 
children. Cochrane Database of Systematic Reviews 2019, Issue 4. Art. No.: CD001534. 
DOI: 10.1002/14651858.CD001534.pub4. 

  























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14. Jonathan Kaufman, Patrick Fitzpatrick, Shidan Tosif, Sandy M Hopper, Susan M Donath, 
Penelope A Bryant, Franz E Babl., Faster clean catch urine collection (Quick-Wee method) 
from infants: randomised controlled trial. BMJ 2017;357:j1341 
http://dx.doi.org/10.1136/bmj.j1341  

15. Manar O. Lashkar, PharmD, BCPS1, and Milap C. Nahata, MS, PharmD. Antimicrobial 
Pharmacotherapy Management of Urinary Tract  Infections in Pediatric Patients, Journal of 
Pharmacy Technology 2018, Vol. 34(2) 62  81. 

16. Mark H. Ebell, MD, MS, University of Georgia, Athens, Georgia Christopher C. Butler, MD, 
The Nuffield Department of Primary Care Health Sciences,  University of Oxford, Oxford, 
United Kingdom Alastair D. Hay, MD, Bristol Medical School, Bristol, United Kingdom., 
Diagnosis of Urinary Tract Infections in Children.  [Online]. From collection of Point-of-Care 
Guides, American Family Physician, 2018 Feb 15; 97(4):273-274.  Available at: 
http://www.aafp.org/afp/poc [Accessed 9 April 2020]. 

17. Kazuyoshi Johnin, Kenichi Kobayashi, Teruhiko Tsuru, Tetsuya Yoshida, Susumu Kageyama 
and Akihiro Kawauchi Department of Urology, Shiga University of Medical Science, Otsu, 
Shiga, Pediatric voiding cystourethrography: An essential examination for urologists but a 
terrible experience for children , Japan. 2018 The Japanese Urological Association. 

18. Nader Shaikh, MD, Alejandro Hoberman, MD. Section Editors: Tej K Mattoo, MD, DCH, 
FRCP, Sheldon L Kaplan, MD Deputy Editor: Mary M Torchia, MD., 2019, Urinary tract 
infections in children: Long-term management and prevention. [ONLINE] Available at: 
https://www.uptodate.com/contents/urinary-tract-infections-in-children-long-term-
management-and-prevention. [Accessed 9 April 2020]. 

19. Nader Shaikh, MD, Alejandro Hoberman, MD Section Editors: Morven S Edwards, MD, Tej K 
Mattoo, MD, DCH, FRCP Deputy Editor: Mary M Torchia, MD., Urinary tract infections in 
infants older than one month and young children: Acute management, imaging, and 
prognosis. Sep 17, 2019. [ONLINE] Available at: https://www.uptodate.com/contents/urinary-
tract-infections-in-infants-older-than-one-month-and-young-children-acute-management-
imaging-and-prognosis. [Accessed 9 April 2020]. 

20. HealthPathways South Australia. 2018. Urinary Tract Infection (UTI) in Children. [ONLINE] 
Available at: https://southaustralia.healthpathwayscommunity.org/index.htm. [Accessed 9 
April 2020]. 

21. SA Health. 2020. WCHN Paediatric Antibacterial Quick Reference Card. [ONLINE]. Available 
at http://inside.wchn.sa.gov.au/webs/pharmacy/ws_pharm_ams.html. [Accessed 2 June 
2021]. 

22. Government of Western Australia, Child and Adolescent Health Service. Perth Children s 
Hospital, Children s Antimicrobial Management Program (ChAMP). Nitrofurantoin Monograph 
  Paediatric. [ONLINE] Available at https://pch.health.wa.gov.au/For-health-
professionals/Childrens-Antimicrobial-Management-Program/Monographs. [Accessed 2 June 
2021]. 

  









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Acknowledgements 
The South Australian Child and Adolescent Health Community of Practice gratefully 
acknowledge the contribution of clinicians and other stakeholders who participated throughout 
the guideline development process particularly:  

Write Group Lead 
Dr Noha Soliman 

Write Group Members 
Dr Sanjeev Khurana 
Dr Sally Kellett 
Carol La Vanda 
Dr Sam Crafter 
Dr Rebecca Cooksey 

SA Paediatric Clinical Practice Guideline Reference Group Members 

South Australian expert Advisory Group on Antimicrobial Resistance 
(SAAGAR) 

Document Ownership &amp; History 
Developed by: SA Child and Adolescent Health Community of Practice 
Contact: Health.PaediatricClinicalGuidelines@sa.gov.au 

Endorsed by:  Commissioning and Performance, SA Health 
Next review due:  10/06/2026 
ISBN number:  978-1-76083-206-3 
PDS reference:  CG343 
Policy history: Is this a new policy (V1)?  Y 
 Does this policy amend or update and existing policy?   N 
 If so, which version? 
 Does this policy replace another policy with a different title? N 
 If so, which policy (title)? 
 
 

Approval 
Date Version 

Who approved New/Revised 
Version Reason for Change 

10/06/21 V1 Lynne Cowan, Deputy CE, 
Commissioning and Performance, SA 
Department for Health and Wellbeing 

Original  Commissioning and  
Performance approved 
version. 

 
  




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Appendices 

APPENDIX 1   EXCERPT FROM THE WCHN PAEDIATRIC EMPIRIC 
ANTIMICROBIAL QUICK REFERENCE 

 

 
 


	Purpose and Scope of PCPG
	Important points
	Abbreviations
	Definition
	Flowchart
	Summary of Practice Recommendations
	Assessment
	Examination
	Diagnosis of UTI
	Urine collection methods
	Investigations for unwell children presenting to Emergency Department
	Other inpatient investigations
	Interpretations of results
	Urine dipstick
	Urine culture
	Treatment of UTI
	Summary of post UTI renal tract imaging
	Criteria for transfer
	Criteria for discharge
	Indications for consideration of referral to Paediatric urology clinic
	Indications for consideration of referral to Paediatric renal clinic

	References
	Acknowledgements
	Document Ownership &amp; History
	Appendices
	APPENDIX 1   EXCERPT FROM THE WCHN PAEDIATRIC EMPIRIC ANTIMICROBIAL QUICK REFERENCE


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