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New guidance for complex UTIs in kids
The guidelines specifically for complicated infections cover diagnosis and management according to determining features.
UTI in children is a common patient presentation, with girls more likely to present with the infection.
New guidelines could change the way urinary tract infections (UTIs) in children are treated and improve outcomes by better-defining what complicated UTIs are.
Commissioned by the European Society of Paediatric Infectious Diseases and led by Melbourne’s Murdoch Children’s Research Institute (MCRI), the guidelines offer recommendations specifically for more complex paediatric UTIs, with the aim to address existing gaps in current guidelines and improve treatment outcomes.
Lead author Associate Professor Penelope Bryant, from the MCRI, told newsGP the new guidelines clearly define which UTI should be assessed as complicated.
‘The majority of UTI are uncomplicated and well managed in primary care, but it’s good to know the difference, and these guidelines support GP decision-making regarding when to manage and when to refer to ED or for ongoing follow-up,’ she said.
The guidelines recommend which investigations in addition to those for uncomplicated UTI should be considered, and whether a child needs blood tests and/or imaging, as well as management regarding antibiotic route, choice and duration.
It also recommends when a narrow spectrum antibiotic is safe and when a broad-spectrum antibiotic should be given empirically, and advice regarding which children need antibiotic prophylaxis, follow-up imaging and referral to urology.
According to the authors, a ‘harmonised definition’ of complicated UTI does not exist and management recommendations in existing guidelines are ‘often neglected’.
The research defines four key areas to determine management recommendations for children and adolescents – the definition of complicated UTI, investigations, treatment and follow-up. Those with complicated UTIs are categorised into five sub-groups:
- anatomical/functional urological abnormalities
- multiple UTI recurrences
- severe clinical presentation
- non-urological underlying conditions
- neonates.
The authors say these sub-groups are the most likely to need additional investigations at diagnosis and during the course of infection.
Tasmanian GP and Chair of RACGP Specific Interests Child and Young Person’s Health, Dr Tim Jones, welcomes the study recognising more complicated cases of UTI.
‘UTI is a very common presenting complaint in children to GPs,’ Dr Jones told
newsGP.
‘It would fall within the top 30 presentations to GPs for kids or adults using the BEACH dataset on GP presentations.’
While Dr Jones agrees most UTIs are safely managed in the community with appropriate investigations and oral antibiotics, he said the study fills some knowledge gaps around treating more serious cases.
‘It’s good to see recognition of kids with more complex UTI backgrounds within this study and clear delineation of who can receive treatment in the community with oral antibiotics and who requires initial IV antibiotic therapy,’ he said.
‘In this age of crowded emergency departments and also with the increasing importance of antimicrobial stewardship, this is becoming very important.’
The new guideline comes off the back of another
recent MCRI project – a tool that detects which children have serious infections and need to be admitted to hospital, while reducing unnecessary stays for others.
Associate Professor Byrant says with UTI the commonest proven bacterial infection in children that GPs prescribe antibiotics for, almost 8% of girls and 2% of boys will have a UTI by the time they are seven years old. But a proportion will not fall under current guidelines because they are ‘more complicated’.
‘The problem with complicated UTI is partly that it has been defined in multiple ways and partly that children with complicated UTI are often excluded from studies, so the evidence for treatment is lacking,’ she said.
The guideline is comprehensive in addressing existing gaps by first highlighting that complicated UTI is ‘not a uniform entity but rather constitutes a wide range of disease processes’, the authors state, to provide more individualised patient management.
‘Current treatment guidelines focus on uncomplicated UTI, providing extensive and useful information on symptoms, urine collection and analysis and treatment options,’ Associate Professor Bryant said.
‘Management of complicated UTI, including when IV antibiotics may or may not be needed, and when referral is required, has largely been excluded.
‘By providing a clear classification, and then for each sub-group recommended investigations, treatment and follow-up, these guidelines aim to fill a gap in existing management.’
Regardless of the sub-group, the guidelines highlight that accurate diagnosis is the ‘critical first step’ in managing children for which additional investigations might be required.
Dr Jones also notes the importance of the guideline’s role in highlighting antimicrobial resistance.
‘It is good to see [ways of] accurately confirming the presence of UTI as we are seeing an increasing need to use very broad antibiotics initially to cover resistant bugs,’ he said.
‘So making sure as GPs we are accurately testing for the presence of UTI and ceasing/narrowing the spectrum of antibiotic treatment if those initial investigations support it is highly important.’
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antibiotics children’s health paediatric infections urinary tract infection UTI
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