What is the recommended treatment for urinary tract infections (UTI) in children?

From the Guidelines

The recommended treatment for urinary tract infections (UTIs) in children typically involves antibiotics, with the specific regimen depending on the child's age, infection severity, and local resistance patterns. For uncomplicated UTIs, oral antibiotics such as trimethoprim-sulfamethoxazole (4-6 mg/kg/dose of trimethoprim twice daily), amoxicillin-clavulanate (20-40 mg/kg/day divided twice daily), or cephalexin (25-50 mg/kg/day divided into 3-4 doses) are commonly prescribed for 7-10 days 1.

Key Considerations

• For infants under 3 months or children with severe infections, hospitalization with intravenous antibiotics like ampicillin plus gentamicin or a third-generation cephalosporin may be necessary 1.
• Treatment should begin promptly after obtaining a urine culture, though empiric therapy may start before results are available.
• Adequate hydration is essential during treatment, and fever reducers like acetaminophen or ibuprofen can help manage symptoms.
• Parents should ensure the child completes the full antibiotic course even if symptoms improve quickly, as incomplete treatment can lead to recurrent infections or antibiotic resistance.

Recent Guidelines

The European Association of Urology and European Society for Paediatric Urology guidelines provide a practical approach to the treatment of vesicoureteral reflux (VUR) in children, emphasizing risk analysis and selective indications for diagnostic tests and interventions 1.

• Bladder and bowel dysfunction (BBD) is common in toilet-trained children presenting with UTI with or without primary VUR and increases the risk of febrile UTI and focal uptake defects on a radionuclide scan.
• Continuous antibiotic prophylaxis (CAP) may not be required in every VUR patient, and a practical approach would be to consider CAP until there is no further BBD.

Management Approach

• For children with febrile UTI and high-grade VUR, initial medical treatment is recommended, with surgical care reserved for CAP noncompliance, breakthrough febrile UTIs despite CAP, and symptomatic VUR that persists during long-term follow-up 1.
• Comparison of laparoscopic extravesical versus other surgical approaches may be considered in specific cases.
• Follow-up urine cultures may be needed to confirm the infection has cleared, particularly in younger children or those with 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 recommended treatment for urinary tract infections (UTI) in children 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 (400 mg/80 mg) or 1 (DS) tablet every 12 hours
• 66-88 lb (30-40 kg): 2 tablets (400 mg/80 mg) or 1 (DS) tablet every 12 hours

• The treatment duration is 10 days.

From the Research

Diagnosis and Treatment of UTI in Children

• Urinary Tract Infections (UTI) are a common infection in children, and prompt diagnosis and appropriate treatment are crucial to reduce morbidity 3.
• The symptoms and signs of UTI are nonspecific throughout infancy, with unexplained fever being the most common symptom during the first two years of life 3.
• After the second year of life, symptoms and signs of pyelonephritis include fever, chills, rigor, flank pain, and costovertebral angle tenderness, while lower tract symptoms and signs include suprapubic pain, dysuria, urinary frequency, urgency, cloudy urine, malodorous urine, and suprapubic tenderness 3.

Recommended Treatment

• A urinalysis and urine culture should be performed when UTI is suspected, and prompt antibiotic therapy is indicated for symptomatic UTI based on clinical findings and positive urinalysis 3.
• The choice of antibiotics should take into consideration local data on antibiotic resistance patterns, with current recommendations including a second or third generation cephalosporin and amoxicillin-clavulanate for the treatment of acute uncomplicated UTI 3.
• Parenteral antibiotic therapy is recommended for infants ≤ 2 months and any child who is toxic-looking, hemodynamically unstable, immunocompromised, unable to tolerate oral medication, or not responding to oral medication 3.
• Routine antimicrobial prophylaxis is rarely justified, but continuous antimicrobial prophylaxis should be considered for children with frequent febrile UTI 3.

Additional Considerations

• History and examination findings can be non-specific, so a urine sample is required to diagnose UTI, with bedside dipstick tests useful for screening, but urine culture required for diagnostic confirmation 4.
• The increasing knowledge of the innate immune system will add new predictors and treatment strategies to the management of UTI in children 5.
• Long-term outcome is good for the majority, but individuals with severe scarring can develop hypertension and decline in kidney function 5.
• The effectiveness of different antibiotics, such as amoxicillin/clavulanic acid and trimethoprim, has been compared in various studies, with amoxicillin/clavulanic acid being more effective than a single dose of trimethoprim in treating noncomplicated lower UTI 6.