Any person, 4 weeks to 15 years, presenting with urinary symptoms suggestive of a urinary tract infection including but not limited to dysuria, urinary frequency, odorous urine, haematuria with or without fever.
This protocol is intended to be used by registered and enrolled nurses within their scope of practice and as outlined in The Use of Emergency Care Assessment and Treatment Protocols (PD2024_011). Sections marked triangle or diamond indicate the need for additional prerequisite education prior to use. Check the medication table for dose adjustments and links to relevant reference texts.
History prompts, signs and symptoms
These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.
History prompts
- Presenting complaint
- Onset of symptoms
- Pain assessment
- Urinary and bowel changes
- Fluid intake and output
- Last menstrual period and menarche, consider pregnancy, gynaecological causes and sexual history
- Past admissions
- Medical and surgical history, including spinal injury, recurrent UTIs, genitourinary and renal history
- Urinary catheter present
- Time of last catheter change
- Time of last bag emptying and amount
- Sexual activity
- Pre-hospital treatment
- Current medications
- Known allergies
- Immunisation status
- Current weight
Signs and symptoms
Infants and nonverbal children
- Non-specific symptoms
- Poor feeding
- Nausea and/or vomiting
- Lethargy or reduced activity
- Failure to thrive
- Irritability
- Fever
Older children
- Abdominal or loin pain
- Localised genitourinary pain
- Urinary frequency
- Dysuria
- Changes to continence
- Haematuria
- Pungent smelling urine
- Fever
Red flags
Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.
Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.
Historical
- Age less than 6 months old
- Urinary tract abnormalities
- Neurogenic bladder or uropathy
- Kidney disease or single kidney
- Recent abdominal or urological surgery
- Immunocompromised or steroid therapy
Clinical
- If sepsis suspected, switch to sepsis (suspected) protocol
- Urinary retention
- Haematuria, i.e. frank blood or clots
- Severe pain requiring opioid analgesia
- Vaginal or urethral purulent discharge, consider an alternate cause
Remember child or adolescent at risk: patient or carer concern, suspected non-accidental injury or neglect, multiple comorbidities or unplanned return.
Clinical assessment and specified intervention (A to G)
If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.
Position
Assessment | Intervention |
---|---|
General appearance/first impressions | Position of comfort |
Airway
Assessment | Intervention |
---|---|
Patency of airway | Maintain airway patency Consider airway opening manoeuvres and positioning |
Breathing
Assessment | Intervention |
---|---|
Respiratory rate and work of breathing Consider auscultation of chest (breath sounds) Oxygen saturation (SpO2) | Assist ventilation as clinically indicated Apply oxygen to maintain SpO2 over 93% |
Circulation
Assessment | Intervention |
---|---|
Perfusion (capillary refill, skin warmth and colour) Heart rate Blood pressure Cardiac rhythm | Assess circulation Attach cardiac monitor if BP/HR are within the Yellow or Red Zones, or where clinically relevant, e.g. irregular pulse, palpitations, syncope, shock, respiratory compromise, cardiac history or clinical concern Consider 12 lead ECG |
IVC and/or pathology | Insert IV cannula, if trained and clinically indicated If unable to obtain IV access, consider intraosseous, if trained |
Signs of shock: tachycardia and CRT 3 seconds and over and/or abnormal skin perfusion and/or hypotension | If signs of shock present, give sodium chloride 0.9% at 20 mL/kg IV/intraosseous bolus once only, maximum dose 1000 mL |
Disability
Assessment | Intervention |
---|---|
AVPU | If AVPU shows reduced level of consciousness, continue to assess GCS, pupillary response and limb strength |
GCS, pupillary response and limb strength | Obtain baseline and repeat assessment as clinically indicated |
Pain | Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment |
Exposure
Assessment | Intervention |
---|---|
Temperature | Measure temperature |
Head-to-toe inspection, including posterior surfaces | Check and document any abnormalities
Inspect indwelling urinary devices if present Assess for blockages, kinks, blood or sedimentation |
Fluids
Assessment | Intervention |
---|---|
Hydration status | Assess fluids, in and out. Document on fluid balance chart. Include gastrointestinal losses |
Nausea and/or vomiting | If present, see nausea and/or vomiting section |
Glucose
Assessment | Intervention |
---|---|
BGL |
Measure BGL, where clinically relevant or of concern. See medication table for 40% glucose gel dosing If BGL between 2 mmol/L and 3 mmol/L and NOT symptomatic (Yellow Zone criteria):
If BGL less than 2 mmol/L OR symptomatic (Red Zone criteria) OR unable to tolerate oral glucose:
|
Repeat and document assessment and observations to monitor responses to interventions, identify developing trends and clinical deterioration. Escalate care as required according to the local CERS protocol.
Focused assessment
Complete an abdominal focused assessment.
Complete a dehydration focused assessment.
Precautions and notes
- Consider more serious illness in infants less than three months old.
- Signs of a urinary tract infection can be non-specific in young children and may include fever, vomiting, poor feeding, lethargy and irritability.
- Nappy rash, vulvovaginitis, balanitis, cellulitis and threadworm can cause localised pain and discomfort in the genital area. Provide analgesia and comfort measures.
- If sexual abuse is suspected or disclosed refer to local sexual assault protocols.
Interventions and diagnostics
Specific treatment
Urinary retention
- Urinary retention may occur with dysuria.
- Patient may experience abdominal distention, discomfort and absence of urine.
- Provide appropriate analgesia.
- Assess bladder with a bedside bladder scanner, if available.
- Place the child in a warm bath to encourage urination.
- If unable to pass urine, a catheter may need to be placed to empty the bladder.
- Escalate as per local CERS protocol for management advice.
Analgesia
If pain score 1–6 (mild–moderate):
Give paracetamol 15 mg/kg orally once only, maximum dose 1000 mg
and/or ibuprofen, if 3 months and over, 10 mg/kg orally once only, maximum dose 400 mg
If severe pain present, give analgesia and escalate as per local CERS protocol.
Consider non-pharmacological pain relief (appendix).
Nausea and/or vomiting
If nausea and/or vomiting is present and over 6 months give:
ondansetron:
- 8–15 kg: 2 mg, orally once only
- 15–30 kg: 4 mg, orally once only
- Over 30 kg: 8 mg, orally once only.
Procedural analgesia
For pain relief required during procedures only, not used to replace appropriate analgesia.
Sucrose 24%
- 1–18 months: give 1–2 mL orally per procedure
- Maximum dose:
- 1–3 months: up to 5 mL in 24 hours
- 3–18 months: up to 10 mL in 24 hours.
Repeat as needed up to the maximum dose.
Nitrous oxide and oxygen mix inhalation
Only give nitrous:
- if required education and training have been completed
- according to state and local guidelines
- when an additional trained clinician is available to complete the procedure.
12 months and over:
- Attach oxygen saturation probe for monitoring.
- Apply 100% oxygen with face mask, ensuring adequate seal. Aim for smallest fitting mask.
- Give 70% nitrous oxide with 30% oxygen for 3–4 minutes before starting procedure.
- If wall nitrous oxide/oxygen is unavailable, pre-mixed 50% nitrous oxide with 50% oxygen (Entonox) can be used.
- After procedure: give 100% oxygen for 3–5 minutes, to prevent diffusion hypoxia.
- If the nitrous oxide is removed for over 30 seconds at any stage: apply 100% oxygen for 3 minutes, to prevent diffusion hypoxia.
Radiology
Not usually indicated. If there is concern for urgent radiology, escalate care as per local CERS protocol.
Pathology
- Urinalysis
- Patient who can void in the toilet: mid-stream urine
- Patient who is not toilet trained: clean catch or catheter urine
- Send for MC&S. Keep the sample refrigerated if transport is delayed
- Refer to urine sampling appendix for further detail
- Seriously unwell child: FBC, UEC, blood cultures
Medications
The patient’s weight is mandatory for calculating fluid and medication doses.
The Broselow Tape or APLS weight table (appendix) can be used only in circumstances where the patient cannot be weighed.
The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.
Drag the table right to view more columns or turn your phone to landscape
Drug | Dose | Route | Frequency |
---|---|---|---|
Glucose 40% gel | 4 weeks–1 year: 1–5 years: 5 g 6–11 years: 10 g 12 years and over : 15 g | Buccal | Repeat after 15 minutes if required |
Ibuprofen H, R | 3 months and over: Maximum dose 400 mg | Oral | Pain score 1–10 Once only |
12 months and over: | Inhalation | Used during procedures only Once only | |
OR | |||
12 months and over: | |||
Over 6 months and 8–15 kg: 15–30 kg: Over 30 kg: | Oral | Once only | |
0.25–15 L/min, device dependent | Inhalation | Continuous | |
15 mg/kg Maximum dose 1000 mg | Oral | Pain score 1–10 Once only | |
20 mL/kg Maximum dose 1000 mL | IV/intraosseous | Bolus Once only | |
1–18 months: Maximum dose 3–18 months: | Oral | Used during procedures only Repeat if required to maximum dose |
Medications with contraindications or requiring dose adjustment are marked:
- H for patients with known hepatic impairment
- R for patients with known renal impairment.
Escalate to medical or nurse practitioner.
References
- National Institute for Health and Clinical Excellence (NICE). Urinary tract infection in under 16s: diagnosis and management. United Kingdom: National Institute for Health and Clinical Excellence (NICE); 2018 [cited 1 Mar 2023]. Available from: https://www.nice.org.uk/guidance/cg54
- The Royal Children's Hospital Melbourne. Sucrose (oral) for procedural pain management in infants. Melbourne: Victoria Health; 2021 [cited 23 Feb 2023]. Available from: https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Sucrose_oral_for_procedural_pain_management_in_infants/#
- Desai DJ, Gilbert B, McBride CA. Paediatric urinary tract infections: Diagnosis and treatment. Australian family physician. 2016;45(8):558-64.
- The Royal Children's Hospital Melbourne. Nitrous Oxide - oxygen mix. Melbourne: Victoria Health; 2021 [cited 23 Feb 2023]. Available from: https://www.rch.org.au/clinicalguide/guideline_index/Nitrous_Oxide_Oxygen_Mix/
- Fernández MLH, Merino NG, García AT, et al. A new technique for fast and safe collection of urine in newborns. Archives of disease in childhood. 2013;98(1):27-9.
- The Sydney Children's Hospital Network. Meds 4 Kids Dosing Guide. Australia: NSW Health; 2023 [cited 23 Feb 2023]. Available from: https://webapps.schn.health.nsw.gov.au/meds4kids/
- McTaggart S, Danchin M, Ditchfield M, et al. KHA‐CARI guideline: diagnosis and treatment of urinary tract infection in children. Nephrology. 2015;20(2):55-60.
- MIMS Australia. Clinical Resources. Australia: MIMS Australia Pty Ltd; 2022 [cited 2 Feb 2023]. Available from: https://www.mimsonline.com.au.acs.hcn.com.au/Search/Search.aspx
- The Royal Children's Hospital Melbourne. Clinical practice guidelines: Urinary tract infection. Melbourne: Victoria Health; 2019 [cited 1 Mar 2023]. Available from: https://www.rch.org.au/clinicalguide/guideline_index/Urinary_Tract_Infection_Guideline/
- NSW Health. Australian Medicines Handbook. Australia: Australian Government, NSW; 2022 [cited 23 Feb 2023]. Available from: https://amhonline.amh.net.au.acs.hcn.com.au/
- NSW Health. AMH Children's Dosing Companion. Australia: Australian Government, NSW; 2023 [cited 23 Feb 2023]. Available from: https://childrens.amh.net.au/auth
- The Royal Children's Hospital Melbourne. Oxygen delivery. Melbourne: Victoria Health; 2017 [cited 23 Feb 2023]. Available from: https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Oxygen_delivery/
Evidence informed |
Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process. |
Collaboration |
This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol. |
Currency | Due for review: Jan 2026. Based on a regular review cycle. |
Feedback | Email ACI-ECIs@health.nsw.gov.au |
Accessed from the Emergency Care Institute website at https://aci.health.nsw.gov.au/ecat/paediatric/urinary-tract-infection