What is the first-line treatment for pediatric urinary tract infections (UTIs)?

From the Guidelines

The first-line treatment for pediatric urinary tract infections (UTIs) is oral antibiotics, typically trimethoprim-sulfamethoxazole (TMP-SMX) at a dose of 6-12 mg/kg/day of the TMP component divided twice daily, or amoxicillin-clavulanate at 20-40 mg/kg/day divided three times daily, for 7-10 days. For infants under 2 months or children with pyelonephritis, systemic illness, vomiting, or inability to tolerate oral medication, initial parenteral therapy with a third-generation cephalosporin like ceftriaxone (50-75 mg/kg/day) is recommended, often followed by oral antibiotics once the child improves 1.

Key Considerations

• Treatment should begin promptly after obtaining a urine culture, but before results are available.
• Local antibiotic resistance patterns should guide the choice of antibiotic, as E. coli resistance to ampicillin and TMP-SMX is increasing in many regions 1.
• Adequate hydration should be maintained throughout treatment, and fever can be managed with acetaminophen or ibuprofen.
• Follow-up urine cultures are generally not needed if symptoms resolve, but children with recurrent UTIs or abnormal urinary tract anatomy may require prophylactic antibiotics and imaging studies to identify underlying structural abnormalities.

Additional Recommendations

• Ultrasonography of the kidneys and bladder should be performed to detect anatomic abnormalities 1.
• Voiding cystourethrography (VCUG) is not recommended routinely after the first UTI, but may be indicated if renal and bladder ultrasonography reveals hydronephrosis, scarring, or other findings that would suggest either high-grade VUR or obstructive uropathy 1.
• Antimicrobial prophylaxis may be considered in certain cases, such as children with vesicoureteral reflux (VUR) or recurrent UTIs, but the benefits and risks should be carefully weighed 1.

Treatment Duration

• The total course of therapy should be 7 to 14 days, with the minimal duration selected being 7 days 1.

Special Considerations

• Neonates with UTI have a high incidence of urinary anomalies, and concomitant bacteremia with UTI is common 1.
• Children with recurrent or complicated UTI may require additional evaluation and treatment, including imaging studies and prophylactic antibiotics 1.

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 first-line treatment for pediatric urinary tract infections (UTIs) is trimethoprim/sulfamethoxazole. The recommended dosage is:

• 40 mg/kg sulfamethoxazole and 8 mg/kg trimethoprim per 24 hours
• Given in two divided doses every 12 hours
• For a duration of 10 days 2

From the Research

Treatment of Pediatric Urinary Tract Infections (UTIs)

The first-line treatment for pediatric UTIs depends on the age and clinical presentation of the child.

• For neonates younger than 28 days with a febrile UTI, hospitalization and parenteral amoxicillin and cefotaxime are recommended 3.
• For infants from 28 days to 3 months who appear clinically ill with a febrile UTI, hospitalization and parenteral administration of a 3rd generation cephalosporin or gentamicin are recommended 3.
• For children with complicated pyelonephritis, hospitalization and parenteral ceftriaxone or gentamicin are recommended until clinically improved and without fever for 24 hours, followed by completion of 10 to 14 days of therapy with an oral antibiotic 3.
• For children with uncomplicated pyelonephritis, rehydration in the outpatient department (if necessary) and parenteral ceftriaxone or gentamicin until without fever for 24 hours, followed by completion of 10 to 14 days of therapy with an oral antibiotic are recommended 3.
• For children with cystitis who are mildly symptomatic, supportive care until the result of the urine culture and sensitivity are available is recommended, while those who are moderately to severely symptomatic should receive an oral antibiotic and supportive care immediately 3.

Antibiotic Resistance

The increasing prevalence of antibiotic-resistant uropathogens has complicated the treatment of UTIs 4, 5, 6.

• The resistance rate for trimethoprim/sulfamethoxazole was found to be 34% in one study, with all resistant microorganisms being E. coli 6.
• Fluoroquinolone resistance rates were found to be as high as 16.4% in another study 6.
• The use of new antimicrobials, such as nitrofurantoin, fosfomycin, and pivmecillinam, may be effective in treating UTIs caused by antibiotic-resistant bacteria 5.