What is the treatment for Urinary Tract Infection (UTI) in pediatric patients?

From the Guidelines

For pediatric UTI treatment, the primary approach is antibiotic therapy, with nitrofurantoin being a reasonable drug of choice for uncomplicated cystitis, and TMP/SMX or a first-generation cephalosporin representing reasonable first-line agents for pyelonephritis, depending on local resistance rates, as recommended by the most recent guidelines 1.

Treatment Approach

The treatment of UTIs in pediatric patients should be guided by the severity of the infection and the presence of underlying risk factors.

• For uncomplicated cystitis, nitrofurantoin is a suitable option due to its efficacy and ability to spare the use of more systemically active agents for other infections.
• For pyelonephritis, TMP/SMX or a first-generation cephalosporin are reasonable choices, but the selection should be based on local resistance rates.
• Ceftriaxone is recommended for patients who require intravenous therapy, unless there are risk factors for multidrug resistance.

Considerations

When selecting empirical treatment regimens, it's essential to consider the presence of risk factors for antimicrobial resistance and clinical severity, as these factors play a crucial role in the choice of empirical treatment 1.

• Agents with antipseudomonal activity should only be used in patients with risk factors for nosocomial pathogens.
• The use of carbapenem therapy empirically may be reasonable in certain cases.

Additional Management

In addition to antibiotic therapy, management of pediatric UTIs may involve:

• Obtaining a urine sample for culture and sensitivity testing to guide treatment if the initial empiric therapy is ineffective.
• Encouraging increased fluid intake to help flush out bacteria.
• Using antipyretics like acetaminophen or ibuprofen for fever and discomfort.
• Considering a shorter course of antibiotics (3-5 days) for older children with lower UTIs.
• Completing the full course of antibiotics to prevent antibiotic resistance and reduce the risk of recurrent infections.
• Performing follow-up urine tests to ensure the infection has cleared.
• Investigating underlying anatomical abnormalities or vesicoureteral reflux in cases of recurrent UTIs.

From the FDA Drug Label

Children: The recommended dose for children with urinary tract infections or acute otitis media is 40 mg/kg sulfamethoxazole and 8 mg/kg trimethoprim per 24 hours, given in two divided doses every 12 hours for 10 days. The treatment for Urinary Tract Infection (UTI) in pediatric patients is 40 mg/kg sulfamethoxazole and 8 mg/kg trimethoprim per 24 hours, given in two divided doses every 12 hours for 10 days 2.

• The dosage is based on the child's weight, with the following guidelines:
  • 22-44 lb (10-20 kg): 1 tablet every 12 hours
  • 66-88 lb (30-40 kg): 1½ tablets every 12 hours
  • 88 lb (40 kg) or more: 2 tablets every 12 hours 3.

From the Research

Treatment for Urinary Tract Infection (UTI) in Pediatric Patients

• The treatment of UTI in pediatric patients should be based on practical considerations regarding age and presentation, with adjustment of the initial antimicrobial treatment according to antimicrobial sensitivity testing 4.
• For neonates younger than 28 days with a febrile UTI, hospitalization and treatment with parenteral amoxicillin and cefotaxime is recommended, followed by outpatient treatment with an oral antibiotic to complete 14 days of therapy 5.
• Infants from 28 days to 3 months who appear clinically ill with a febrile UTI should be hospitalized and receive supportive care and parenteral administration of a 3rd generation cephalosporin or gentamicin 5.
• Children with complicated pyelonephritis should be hospitalized and receive supportive care and parenteral ceftriaxone or gentamicin, while those with uncomplicated pyelonephritis can be managed as outpatients with parenteral ceftriaxone or gentamicin and then oral antibiotics 5.
• For children with cystitis, oral antibiotic treatment can be started immediately, with the choice of antibiotic depending on the local resistance pattern of E. coli and the patient's ability to take oral agents 6.
• First-line empiric therapy for upper UTI can include pivmecillinam or amoxicillin-clavulanic acid, while nitrofurantoin is an excellent first choice for lower UTI 6.
• Cephalexin may be the most appropriate first-line choice for management of outpatient UTI, especially since many E. coli isolates are susceptible to it 7.
• Antibiotic stewardship in the outpatient setting can help reduce unnecessary antibiotic exposure in the management of pediatric UTI 7.

Antibiotic Resistance and Treatment

• There is high antibiotic resistance in children with UTI, with varying patterns of uropathogen antimicrobial resistance depending on region and time 8.
• A low level of resistance was noted against cefepime, ertapenem, norfloxacin, and meropenem, while there was no resistance against amikacin 8.
• The trends of antibiotic susceptibility patterns should be analyzed periodically to select the appropriate regimen for UTI treatment 8.