What is the guidance on treating Urinary Tract Infections (UTI) in pediatric patients?

From the Guidelines

The treatment of urinary tract infections (UTIs) in children typically involves antibiotics, with the specific approach depending on the child's age, severity of infection, and whether it's a lower or upper UTI, as recommended by the most recent guidelines 1. For uncomplicated lower UTIs, oral antibiotics such as trimethoprim-sulfamethoxazole (4-6 mg/kg/day divided twice daily), amoxicillin-clavulanate (20-40 mg/kg/day divided twice daily), or cephalexin (25-50 mg/kg/day divided four times daily) are commonly prescribed for 7-10 days.

Key Considerations

• For febrile UTIs or pyelonephritis, a 10-14 day course is recommended, potentially starting with parenteral antibiotics like ceftriaxone (50-75 mg/kg/day) for 24-48 hours before transitioning to oral therapy.
• Infants under 3 months typically require hospitalization and intravenous antibiotics.
• Adequate hydration is essential during treatment, and follow-up urine cultures may be needed to confirm resolution.
• Imaging studies like renal ultrasound are often recommended after a first febrile UTI to identify anatomical abnormalities.
• Antibiotic selection should consider local resistance patterns, and treatment should be adjusted based on urine culture results. Some key points to consider when treating UTIs in children include:
• The role of imaging is to evaluate for underlying urologic abnormalities and guide treatment, with ultrasound being the only study that is usually appropriate for initial evaluation 1.
• The top-down approach, which focuses on the diagnosis of acute pyelonephritis and renal scarring, may be preferred in some cases, with DMSA followed by cystourethrography if DMSA renal scan suggests pyelonephritis 1.
• Prompt treatment is crucial to prevent complications such as renal scarring, especially in young children whose developing kidneys are more vulnerable to damage from infection. It's also important to note that:
• The incidence of acute pyelonephritis in the absence of documented VUR is much too high to be explained only by intermittent VUR 1.
• Previous episodes of pyelonephritis or VUR increase the risk for recurrent pyelonephritis.
• Absence of fever does not exclude development of pyelonephritis.
• Cystitis in the absence of pyelonephritis is usually not associated with long-term sequelae. In summary, the treatment of UTIs in children should be guided by the most recent and highest quality evidence, with a focus on prompt antibiotic treatment, adequate hydration, and imaging studies to identify anatomical abnormalities, as recommended by the American College of Radiology Appropriateness Criteria 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 following table is a guideline for the attainment of this dosage: Children 2 months of age or older: Weight Dose – every 12 hours lb kg Tablets 22 10 1 44 20 1 66 30 1½ 88 40 2 or 1 DS tablet

The recommended guidance for treating Urinary Tract Infections (UTI) in pediatric patients is to administer 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 a guideline table provided for attainment of the recommended dose.
• Pediatric patients less than 2 months of age should not be given this medication 3 3.
• For patients with impaired renal function, a reduced dosage should be employed, with specific recommendations based on creatinine clearance 2 3 3.

From the Research

Guidance on Treating Urinary Tract Infections (UTI) in Pediatric Patients

• The treatment of UTI in pediatric patients depends on various factors such as age, severity of symptoms, and local antibiotic resistance patterns 4, 5, 6, 7, 8.
• For neonates and infants, parenteral antibiotics such as amoxicillin and cefotaxime are recommended, while for older children, oral antibiotics such as cephalexin or fosfomycin trometamol may be used 6, 7.
• The choice of antibiotic should be guided by local susceptibility patterns, and antibiotic de-escalation should be practiced once the result of the urine culture is known 7.
• For uncomplicated UTI, a 5-7 day course of oral antibiotics is recommended, while for complicated UTI, a 10-14 day course of antibiotics may be necessary 6, 8.
• 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 8.

Antibiotic Recommendations

• Second-generation cephalosporin (children under 6 years) and fosfomycin trometamol (over 6 years) are recommended as empiric therapy for UTI 7.
• Third-generation cephalosporins are recommended for pyelonephritis, and ampicillin should be added in infants less than 3 months old 7.
• A combination of intravenous ampicillin and intravenous/intramuscular gentamycin or a third-generation cephalosporin can be used in severe cases 8.

Diagnosis and Treatment

• Urine cultures collected before starting antibiotics are always required for diagnosis, and clean-catch (midstream) specimens should be collected for urine culture 7.
• Prompt antibiotic therapy is indicated for symptomatic UTI based on clinical findings and positive urinalysis to eradicate the infection and improve clinical outcome 8.
• Imaging studies should be judiciously utilized to minimize exposure of children to radiation 8.