What is the recommended treatment for a pediatric patient with a urinary tract infection (UTI)?

Treatment of Pediatric Urinary Tract Infections

For pediatric urinary tract infections (UTIs), the recommended treatment is a 7-14 day course of antibiotics, with the choice of agent based on local antimicrobial sensitivity patterns and adjusted according to culture results. 1

Diagnosis Confirmation

Before initiating treatment, proper diagnosis is essential:

• Urine specimen should be collected via:
  • Catheterization or suprapubic aspiration for non-toilet-trained children
  • Clean-catch midstream urine for toilet-trained children 1, 2
• Positive culture criteria:
  • ≥50,000 CFU/mL of a single urinary pathogen 1
  • Any growth from suprapubic aspiration 2

Treatment Algorithm

Route of Administration

1. Oral therapy is appropriate for most children who:

   • Are clinically stable
   • Can tolerate oral medications
   • Have reliable caregivers 1

2. Parenteral therapy is indicated for children who:

   • Appear toxic or severely ill
   • Cannot retain oral medications
   • Have questionable adherence to oral therapy 1

Empiric Antibiotic Selection

Oral Options:

• First-line options:
  • Amoxicillin-clavulanate: 20-40 mg/kg/day in 3 doses
  • Cephalosporins:
    • Cefixime: 8 mg/kg/day in 1 dose
    • Cefpodoxime: 10 mg/kg/day in 2 doses
    • Cephalexin: 50-100 mg/kg/day in 4 doses 1, 3
  • Trimethoprim-sulfamethoxazole: 8 mg/kg trimethoprim and 40 mg/kg sulfamethoxazole per day in 2 doses (for children ≥2 months) 4

Parenteral Options:

• First-line options:
  • Ceftriaxone: 75 mg/kg every 24 hours
  • Cefotaxime: 150 mg/kg/day divided every 6-8 hours
  • Gentamicin: 7.5 mg/kg/day divided every 8 hours 1, 3

Treatment Duration

• 7-14 days for febrile UTIs/pyelonephritis 1
• 3-5 days may be sufficient for simple cystitis in older children 1, 5

Special Considerations

Age-Specific Approaches

• Neonates (<28 days):

  • Require hospitalization and parenteral therapy
  • Consider ampicillin plus cefotaxime or gentamicin 6

• Infants (28 days to 3 months):

  • If ill-appearing: hospitalize with parenteral therapy
  • If well-appearing: may be managed as outpatients with daily parenteral antibiotics until afebrile 6

Important Cautions

• Avoid nitrofurantoin in febrile UTIs/pyelonephritis as it does not achieve therapeutic concentrations in the renal parenchyma 1, 3
• Do not treat asymptomatic bacteriuria as it may be harmful and promote antimicrobial resistance 1
• Adjust therapy based on culture results as soon as available 1

Follow-up and Imaging

• Renal and bladder ultrasonography (RBUS) should be performed in children with febrile UTIs to detect anatomical abnormalities 1
• Clinical improvement, including fever resolution, typically occurs after 48-72 hours of appropriate treatment 1
• Consider additional workup if no improvement within 48-72 hours 1

Antimicrobial Resistance Considerations

• Local resistance patterns should guide empiric therapy choices 1, 2
• E. coli accounts for 80-90% of pediatric UTIs 5
• Rising resistance to ampicillin and trimethoprim-sulfamethoxazole has been observed over time 7
• Cephalosporins generally maintain good activity against common uropathogens 7

By following this evidence-based approach to treating pediatric UTIs, clinicians can effectively manage infections while minimizing complications and preventing long-term renal damage.