UTI: Urinary Tract Infection

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Updated by: Coleen Weber Rosen DNP, FNP-C
Updated on: 2/207

Co-management guidelines

To support collaborative care, we have developed guidelines for our community providers to utilize when referring to, and managing patients with, the pediatric specialists at Children's Wisconsin. These guidelines provide protocols for jointly managing patient cases between community providers and our pediatric specialists.


Signs and symptoms

  • Upper tract: fever, nausea/vomiting, flank pain, general malaise
  • Lower tract: dysuria, frequency/urgency, incontinence, suprapubic pain, change in urine odor or color
  • Neonates/Infants: fever, irritability, poor feeding, vomiting, diarrhea, failure to thrive, jaundice, sepsis


  • 75% of urinary tract infections are cause by Escherichia coli. The next most common pathogens are Klebsiella and Proteus, followed by Staphylococcus and Enterococcus.

Referring provider's initial evaluation and management:


  • Urinalysis suggestive of infection (pyuria and/or bacteriuria) AND > 50,000 colony‐forming units (CFUs) per mL of a uropathogen cultured from a specimen obtained through catheterization
  • In a symptomatic child, positive urinalysis AND > 100,000 CFUs/mL of a single uropathogen from a voided clean‐catch specimen is also diagnostic


  • Leukocyte esterase test: 94% sensitive in the context of clinically suspected UTI
  • Nitrite test: highly specific; not sensitive in children who empty their bladders frequently
  • Culture results of urine collected in a bag applied to the perineum are only valid when negative

When to initiate referral/ consider refer to Urology Clinic:

Recurrent UTIs that are refractory to the recommended treatment:

  1. After the 1st episode of pyelonephritis in a child < 2="" years="" />
  2. After the 2nd episode of pyelonephritis in a child > 2 years old
  3. Abnormal bladder or renal ultrasound
  4. VCUG positive for vesicoureteral reflux, obstruction, or bladder abnormality

What can referring provider send to Urology Clinic?

  • Using Epic
  • Please complete the external referral order
    In order to help triage our patients and maximize the visit, the following information would be helpful include with your referral order:
    • Urgency of the referral
    • What is the key question you would like answered?

    Note: Our office will call to schedule the appointment with the patient.

  • Not using Epic external referral order:
  • In order to help triage our patients maximize the visit time, please fax the above information to (414) 266-1752
    • It would also be helpful to include:
    • Chief complaint, onset, frequency
    • Recent progress notes
    • Labs and imaging results
    • Other Diagnoses
  • Office notes with medications tried/failed in the past and any lab work that may have been obtained regarding this patient's problems.

Specialist's workup will likely include:

After referral to Urology Clinic:

  1. Your patient will receive testing only if it is warranted.
  2. You will receive consultation letter with assessment and plan within a week of the visit.
  3. You will receive updates any time the patient returns for follow up. You may receive a phone call if there are additional concerns.

Treatment and drugs

  1. Behavior modification: robust hydration and frequent voiding
  2. Treatment of constipation
  3. Antibiotics
  4. RUS and/or VCUG dependent upon number of febrile infections and/or under 6 months of age.

Empiric therapy with oral antibiotics pending culture and sensitivity results :

  • For children < 6 months old: amoxicillin, cephalosporin; close follow‐up with patients within 24 hours is important to monitor oral therapy; intravenous antibiotic treatment is highly recommended in infants who may not tolerate oral treatment
  • For children > 6 months old: amoxicillin, TMP/SMX, cephalosporin

Minimum 7‐day course due to risk of re‐infection

Toxic‐appearing children or those who cannot tolerate oral medications should be treated parenterally

In confirmed cases of high‐grade VUR, consider prophylactic antibiotics.