If using intravenous gentamicin during labour, use once-daily dosing. This guideline covers diagnosing and managing first or recurrent upper or lower urinary tract infection (UTI) in babies, children and young people under 16. Group B Streptococcus (GBS) is one of the many bacteria that normally live in our bodies and which usually cause no harm. Full details of the evidence and the committee's discussion are in evidence reviewI: antifungals. Assume the child has a urinary tract infection (UTI) and give them antibiotics. 1.1.19 Use dipstick testing for babies and children between 3months and 3years with suspected UTI, and: if both leukocyte esterase and nitrite are negative: do not send a urine sample for microscopy and culture unless at least 1 of the criteria in recommendation 1.1.21 apply. This article intends to summarize only the imaging approach . 1.2.3 in babies without red flags and only 1 risk factor or 1 clinical indicator, use clinical judgement to decide: whether it is safe to withhold antibiotics, and, whether the baby's vital signs and clinical condition need to be monitored. It provides the Committee with a basis for discussion when prioritising quality improvement areas for developing the draft quality standard statements and measures. 1.3.6 The Kaiser Permanente neonatal sepsis calculator can be used as an alternative to the framework outlined in recommendation 1.3.5 for babies born after 34+0weeks of pregnancy who are being cared for in a neonatal unit, transitional care or postnatal ward. The level of gentamicin in the baby's bloodstream shortly before a further dose is given. If giving antibiotics because of clinical concerns about possible early- or late-onset neonatal infection, discuss with parents and carers: the risks and benefits in relation to their baby's circumstances, the observations and investigations that might be needed to guide treatment (for example, to help decide when to stop treatment), the preferred antibiotic regimen (including how it will be delivered) and likely duration of treatment, the impact, if any, on where the woman or her baby will be cared for. [2012], 1.15.1 If giving a second dose of gentamicin, measure the trough blood gentamicin concentration immediately before giving the second dose. [2012], 1.6.5 Healthcare professionals with specific experience in neonatal infection should be available every day to give clinical microbiology or paediatric infectious disease advice. They work with us to promote it to commissioners and service providers: changes were made to align this quality standard with the updated NICE guideline on urinary tract infections in under 16s. Intrapartum fever higher than 38C if there is suspected or confirmed bacterial infection. This review focuses on new additions to the literature on management of UTI from January 2011 to September 2012. However, there is not consensus about when to obtain imaging in neonates. [2007], 1.1.17 Immediately refrigerate or use boric acid to preserve urine samples that are to be cultured but cannot be cultured within 4hours of collection. The presence or absence of a single symptom or sign in isolation in either column should not necessarily be used to decide whether or not to test for UTI. In an updated Cochrane review, six studies of children from birth to 18 years of age (n = 1,069) with initial or recurrent UTI compared the effectiveness of prophylactic antibiotic treatment . Normally, urine flows down the urinary tract, from the kidneys, through the ureters, to the bladder. An alternative antibiotic that would be expected to be active against groupB streptococcus based on either sensitivity testing performed on the woman's isolate or on local antibiotic susceptibility surveillance data. Upper urinary tract infections (ie, acute pyelonephritis) may lead to renal scarring, hypertension, and end-stage kidney disease. [2007], 1.2.13 Do not routinely give prophylactic antibiotics to babies and children following first-time UTI. For other definitions see the NICE glossary and the Think Local, Act Personal Care and Support Jargon Buster. 1.11.7 If continuing antibiotics for longer than 48hours for suspected lateonset neonatal infection despite negative blood culture, review the baby at least once every 24hours. [2012, amended 2021], 1.14.6 If the cerebrospinal fluid culture identifies a Gram-positive bacterium other than groupB streptococcus or listeria, seek expert microbiological advice on management. Urinary Tract Infection (UTI) is a common infection in children. This is in line with the NICE antimicrobial prescribing guidelines on pyelonephritis (acute) and urinary tract infection (lower). We check our quality standards every August to make sure they are up to date. 1.3.3 If there are any risk factors for early-onset neonatal infection (see box 1), or if there are clinical indicators of possible early-onset neonatal infection (see box 2): carry out a physical examination of the baby, including an assessment of vital signs. Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding. Up to 7% of girls and 2% of boys have had a UTI by six years of age. Confirmed prelabour rupture of membranes at term for more than 24hours before the onset of labour. [2007], 1.2.5 Give babies and children over 3months with an acute upper UTI antibiotics in line with the NICE guideline on pyelonephritis (acute): antimicrobial prescribing. When a baby who has had a groupB streptococcal infection is discharged from hospital: she should inform her maternity care team that she has had a previous baby with a groupB streptococcal infection. Full details of the evidence and the committee's discussion for the 2022 recommendations are in evidence reviewB: symptoms and signs. Guidelines and recommendations on management of UTI were last published by the Canadian Paediatric Society (CPS) in 2004. Background Early and prompt diagnosis of urinary tract infection (UTI) in neonates has important therapeutic implications. Parent or care-giver concern for change in behaviour, Does not wake, or if roused does not stay awake, Raised respiratory rate: 60breaths per minute or more, Oxygen saturation of less than 90% in air or increased oxygen requirement over baseline, Persistent tachycardia: heart rate 160beats per minute or more, Persistent bradycardia: heart rate less than 100beats per minute, Temperature 38C or more unexplained by environmental factors, Temperature less than 36C unexplained by environmental factors. Give the child antibiotics if the urine test was carried out on a fresh urine sample. Consider testing the urine of babies, children and young people if they are unwell and there is a suspicion of a UTI but none of the signs or symptoms listed in table 1 are present. In a baby with a non-E. coli urinary tract infection that is responding well to antibiotics and has no other features of atypical infection, a non-urgent ultrasound can be requested, to happen within 6weeks. [2012], 1.15.5 Do not withhold a dose of gentamicin because of delays in getting a trough concentration measurement, unless there is evidence of impaired renal function (for example, an elevated serum urea or creatinine concentration, or anuria). If groupB streptococcus is first identified in the mother within 72hours after the baby's birth: ask those directly involved in the baby's care (for example, a parent, carer, or healthcare professional) whether they have any concerns in relation to the clinical indicators listed in box 2, and, identify any other risk factors present, and, look for clinical indicators of infection.Use this assessment to decide on clinical management (see recommendation 1.3.5). The Guideline Directory contains a full list of paediatric guidelines published by the National Institute for Health and Care Excellence (NICE) and the Scottish Intercollegiate Guidelines Network (SIGN), as well as those from other Royal Colleges or paediatric specialty groups which meet the standards for RCPCH endorsement. This quality standard covers diagnosing and managing urinary tract infection in infants, children and young people (under 16). [2021]. Suspected or confirmed infection in another baby in the case of a multiple pregnancy. People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care. If the child has a high or intermediate risk of serious illness or a history of previous UTI, send a urine sample for culture. [2012], 1.15.3 Hospital services should make blood gentamicin concentrations available to healthcare professionals in time to inform the next dosage decision. Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible. 21 Table 1 lists the most common pathogens associated with neonatal UTI. Methods: [2017, amended 2022], 1.1.4 Do not routinely test the urine of babies, children and young people 3months and over who have symptoms and signs that suggest an infection other than a UTI. [2021]. Prevalence rates of a first-time symptomatic UTI are highest in both male and female infants during the first 12 months of life, with a marked reduction after this period. In April 2021 this was an off-label use of vancomycin. [2007], Box 1 Definitions of atypical and recurrent urinary tract infection (UTI), Seriously ill (for more information, refer to the NICE guideline on fever in under5s: assessment and initial management), Failure to respond to treatment with suitable antibiotics within 48hours, Two or more episodes of UTI with acute upper UTI (acute pyelonephritis), or, One episode of UTI with acute upper UTI plus 1 or more episodes of UTI with lower UTI (cystitis), or, Three or more episodes of UTI with lower UTI, 1.3.3 Do not routinely send babies and children over 6months with first-time UTI who respond to treatment for an ultrasound, unless they have atypical UTI as outlined in tables5 and 6. Explore other possible causes of the child's illness. Assume the child does not have a UTI. In a child with a non-E. coli urinary tract infection that is responding well to antibiotics and has no other features of atypical infection, a non-urgent ultrasound can be requested, to happen within 6weeks. Bacteria in the urine with or without UTI. advise the woman that if she becomes pregnant again: that her new baby will be at increased risk of early-onset groupB streptococcal infection, she should inform her maternity care team that she has had a positive group B streptococcal infection test in a previous pregnancy, her maternity care team will offer her antibiotics in labour, inform the woman's GP in writing that there is a risk of groupB streptococcal infection in babies in future pregnancies. VUR is most common in infants and young children. [2007], Assume the baby or child has a urinary tract infection (UTI), Pyuria is positive and bacteriuria is negative, Start antibiotic treatment if the baby or child has symptoms or signs of a UTI, Pyuria is negative and bacteriuria is positive, Assume the baby or child does not have a UTI. See update information for details. [2021]. 1.1.13 When there has been a clinical concern about neonatal infection in a baby, make a post-discharge management plan, taking into account factors such as: the level of the initial clinical concern. Quality standard [QS36] [2012], 1.1.6 Reassure parents and carers that babies who have or are at increased risk of neonatal infection can usually continue to breastfeed, and that every effort will be made to help with this. [2022], 1.1.12 [2021], 1.8.2 Seek early advice from a paediatrician when late-onset infection is suspected in non-inpatient settings. [2012], 1.15.4 Adjust the gentamicin dose interval, aiming to achieve trough concentrations of less than 2mg/litre. [2012], 1.16.2 When deciding on the appropriate care setting for a baby, take into account the baby's clinical needs and the competencies needed to ensure safe and effective care (for example, the insertion and care of intravenous cannulas). [2012], 1.4.4 Do not routinely perform urine microscopy or culture as part of the investigations for early-onset neonatal infection. Assume a diagnosis of acute upper UTI in babies or children who have either: bacteriuria and fever of 38C or higher or, bacteriuria, fever lower than 38C and loin pain or tenderness. NICE guideline [NG195] [2012]. 1.4.8 In babies with clinical signs of umbilical infection, such as a purulent discharge or signs of periumbilical cellulitis (for example, redness, increased skin warmth or swelling): take a swab sample for microscopy and culture and, start antibiotic treatment with intravenous flucloxacillin and gentamicin (see recommendations 1.5.3 and 1.5.4).If the microbiology results show that the infection is not caused by a Gram-negative bacterium, stop the gentamicin. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. 1.1.1 If the sample cannot be collected at the consultation, advise the parents or carers (as appropriate) to collect and return the urine sample as soon as possible, ideally within 24hours. Take urine samples from children and young people before they are given antibiotics. 27 July 2022. 1.4.1 When starting antibiotic treatment in babies who may have early-onset neonatal infection (see recommendations on recognising risk factors and clinical indicators), perform a blood culture before giving the first dose. Guidelines Vesicoureteral Reflux Guideline Management and Screening of Primary Vesicoureteral Reflux in Children (2017) Published 2010, amended 2017 Vesicoureteral reflux (VUR) and urinary tract infections (UTI) may detrimentally affect the overall health and renal function in affected children. It aims to achieve more consistent clinical practice, based on accurate diagnosis and effective management. do not wait for the test results before starting antibiotics. Irritability with no clear cause. Do not give the child antibiotics unless there is good clinical evidence of a UTI (for example, obvious urinary symptoms). Management Scenario: UTI in children Scenario: Recurrent UTI in children Prescribing information Supporting evidence How this topic was developed On this page Managing urinary tract infection Basis for recommendation From birth to 16 years. [2007], 1.1.11 Throughout labour, monitor for any new risk factors. [2012], 1.5.2 Give benzylpenicillin in a dosage of 25mg/kg every 12hours. [2012, amended 2021], 1.1.8 Reassure parents and carers that they will be able to continue caring for and holding their baby according to their wishes, unless the baby is too ill to allow this. Urinary tract infection (UTI) is one of the most common bacterial infections of childhood. [2007], 1.1.16 Use catheter samples or suprapubic aspiration (SPA) when it is not possible or practical to collect urine by non-invasive methods. Kenneth B. Roberts, MD; Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management. Pre-term birth following spontaneous labour before 37weeks' gestation. start antibiotic treatment according to recommendations 1.5.1 to 1.6.7, and. How to use NICE quality standards and how we develop them Quality standards help you improve the quality of care you provide or commission. Full details of the evidence and the committee's discussion are in evidence reviewC: timing of delivery. 1.6.3 In babies given antibiotics because of risk factors for early-onset infection or clinical indicators of possible infection, consider stopping the antibiotics at 36hours if: the initial clinical suspicion of infection was not strong and, the baby's clinical condition is reassuring, with no clinical indicators of possible infection and, the levels and trends of C-reactive protein concentration are reassuring. This section defines terms that have been used in a particular way for this guideline. [2018], 1.2.8 Do not use antibiotics to treat asymptomatic bacteriuria in babies and children. Published: [2012], 1.4.5 Do not perform skin swab microscopy or culture as part of the investigations for early-onset neonatal infection if there are no clinical signs of a localised infection. This guideline includes recommendations on: This guideline updates and replaces NICE guideline CG54 (August 2007). [2007], Responds well to treatment within 48hours, If abnormal consider micturating cystourethrogram (MCUG), Dimercaptosuccinic acid scintigraphy scan 4 to 6months after the acute infection. [2007], 1.3.6 If the baby or child has a subsequent UTI while waiting for a DMSA scan, review the timing of the scan and consider doing it sooner. [2012]. The aim of this study was to evaluate the prevalence of UTI in neonates admitted to a referral neonatal intensive care unit (NICU) and to identify predictors associated with an increased risk of UTI in NICU population. The British National Institute for Health and Care Excellence (NICE) published the "Urinary tract infection in under 16s: diagnosis and management" in 2007 as a guideline for pediatric urinary tract infection (UTI) management, including imaging, prophylaxis and follow-up 1 . It aims to achieve more consistent clinical practice, based on accurate diagnosis and effective management. This guideline covers diagnosing and managing first or recurrent upper or lower urinary tract infection (UTI) in babies, children and young people under 16. Multiple symptoms and signs will probably increase the likelihood that there is a UTI. Find out how to use quality standards and how we develop them. The aim of this Guidelines summary is to provide a simple, effective, economical, and empirical approach to the diagnosis of urinary tract infections (UTIs) and minimise the emergence of antibiotic resistance in the community. [2022]. In April 2021 this was an off-label use of cephalosporins. INTRODUCTION Urinary tract infection (UTI) in neonates (infants 30 days of age) is associated with bacteremia and congenital anomalies of the kidney and urinary tract (CAKUT). In April 2021, this was an off-label use of fluconazole. [2007, amended 2018], 1.2.7 For information about treating babies and children who were already on prophylactic antibiotics who then developed a UTI see the NICE guidelines on pyelonephritis (acute): antimicrobial prescribing, urinary tract infection (lower): antimicrobial prescribing and urinary tract infection (recurrent): antimicrobial prescribing. A process of measuring the concentration of a drug in the bloodstream, to avoid excessive levels that might be associated with adverse effects or to ensure adequate levels for therapeutic effect. Recent findings 1.10.1 For babies with suspected late-onset neonatal infection who are already in a neonatal unit: give a combination of narrow-spectrum antibiotics (such as intravenous flucloxacillin plus gentamicin) as first-line treatment, use local antibiotic susceptibility and resistance data (or national data if local data are inadequate) when deciding which antibiotics to use, give antibiotics that are effective against both Gram-negative and Gram-positive bacteria, if necrotising enterocolitis is suspected, also include an antibiotic that is active against anaerobic bacteria (such as metronidazole). [2012, amended 2021]. Urinary tract infection (UTI) is a significant cause of morbidity in children. For a short explanation of why the committee made the 2021 recommendations and how they might affect practice, see the rationale and impact section on information and support. If Gram-negative infection is confirmed, stop benzylpenicillin. For a short explanation of why the committee made the 2017 recommendations and how they might affect practice, see the rationale and impact section on urine testing. [2021]. Finding more information and committee details, 1.2 Preventing early-onset neonatal infection before birth, 1.3 Risk factors for and clinical indicators of possible early-onset neonatal infection, Kaiser Permanente neonatal sepsis calculator, Management for babies at increased risk of infection, 1.4 Investigations before starting antibiotics in babies who may have early-onset infection, 1.5 Antibiotics for suspected early-onset infection, 1.6 Duration of antibiotic treatment for early-onset neonatal infection, 1.7 Antibiotic-impregnated intravascular catheters for reducing the risk of late-onset neonatal infection, 1.8 Risk factors for and clinical indicators of possible late-onset neonatal infection, 1.9 Investigations before starting antibiotics in babies who may have late-onset infection, 1.10 Antibiotics for late-onset neonatal infection, 1.11 Duration of antibiotic treatment for late-onset neonatal infection, 1.12 Antifungals to prevent fungal infection during antibiotic treatment for late-onset neonatal infection, 1.13 Avoiding routine use of antibiotics in babies, 1.14 Early- and late-onset meningitis (babies in neonatal units), 1.15 Therapeutic drug monitoring for babies receiving gentamicin, NICE's information on making decisions about your care, Royal College of Obstetricians and Gynaecologists has produced guidance on COVID-19 and pregnancy for all midwifery and obstetric services, Royal College of Paediatrics and Child Health has published guidance on COVID-19 for neonatal services, NICE guidelines on patient experience in adult NHS services, babies, children and young people's experience of healthcare, section on communication in the NICE guideline on intrapartum care, rationale and impact section on information and support, evidence reviewA: information and support, NICE's information on prescribing medicines, rationale and impact section on intrapartum antibiotics, evidence reviewB: intrapartum antibiotics, rationale and impact section on women with prolonged prelabour rupture of membranes, managing prelabour rupture of membranes at term, see the NICE guideline on intrapartum care, recommendations 1.4.1 to 1.4.8 on investigations before starting antibiotics, antibiotic treatment according to recommendations 1.5.1 to 1.6.7, recommendations 1.5.1 to 1.5.9 on which antibiotics to use, rationale and impact section on risk factors for and clinical indicators of possible early-onset neonatal infection, evidence reviewD: maternal and neonatal risk factors, recommendations on recognising risk factors and clinical indicators, rationale and impact section on antibiotic-impregnated intravascular catheters for reducing the risk of late-onset neonatal infection, evidence reviewF: intravascular catheters, NHS England Patient Safety Alert on the risk of harm from inappropriate placement of pulse oximeter probes, rationale and impact section on risk factors for and clinical indicators of possible late-onset neonatal infection, evidence reviewE: risk factors for late-onset neonatal infection, recognising risk factors and clinical indicators, NICE guideline on urinary tract infection in under 16s, rationale and impact section on investigations for late-onset neonatal infection, evidence reviewG: investigations before starting treatment, recommendation 1.7.12 in the NICE guideline on sepsis, recommendations 1.15.1 to 1.15.8 on therapeutic drug monitoring for gentamicin, section on meningitis (babies in neonatal units), rationale and impact section on antibiotics for late-onset neonatal infection, rationale and impact section on antifungals to prevent fungal infection during antibiotic treatment for late-onset neonatal infection, rationale and impact section on early- and late-onset meningitis, Think Local, Act Personal Care and Support Jargon Buster.
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