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

Treatment of Urinary Tract Infections in Children

The recommended treatment for urinary tract infections (UTIs) in children includes age-appropriate antibiotics with cephalexin or cefixime as first-line oral options for children older than 28 days, and ampicillin plus ceftazidime or gentamicin for infants 8-21 days old. 1

Diagnosis Confirmation

Before initiating treatment, proper diagnosis is essential:

• A definitive UTI diagnosis requires pyuria and ≥50,000 CFU/mL of a single uropathogen, or pure growth of 250,000 CFUs/mL with bacteriuria or pyuria 1
• Urine specimen collection should be done before administering antibiotics via catheterization or suprapubic aspiration for non-toilet trained children 1

Treatment by Age Group

Neonates and Young Infants (0-21 days)

• First-line therapy: Ampicillin IV/IM (150 mg/kg/day divided every 8h) plus either:
  • Ceftazidime IV/IM (150 mg/kg/day divided every 8h) or
  • Gentamicin IV/IM (4 mg/kg/dose every 24h) 1
• Hospitalization is recommended for this age group 2
• Duration: 10-14 days total course 1

Infants 22-60 days

• First-line therapy: Ceftriaxone IV/IM (50 mg/kg/dose every 24h) 1
• Hospitalization for clinically ill infants; outpatient management possible for non-acutely ill infants 2
• Duration: 10-14 days total course 1

Infants >28 days and Children

• Oral options:
  • Cephalexin 50-100 mg/kg/day in 4 doses or
  • Cefixime 8 mg/kg/day in 1 dose 1
• For children ≥2 months: Trimethoprim-sulfamethoxazole (40 mg/kg sulfamethoxazole and 8 mg/kg trimethoprim per 24 hours, divided in two doses every 12 hours) 3, 4
• Duration: 7-10 days for uncomplicated UTIs, 10-14 days for pyelonephritis 1, 5

Treatment Based on UTI Type

Uncomplicated Cystitis

• Oral antibiotics for 5-7 days 2
• Clinical response typically within 2-3 days 2

Pyelonephritis

• Complicated cases: Initial parenteral therapy until afebrile for 24 hours, then complete 10-14 days with oral antibiotics 2
• Uncomplicated cases: May be managed as outpatients with initial parenteral therapy until afebrile, then oral antibiotics to complete 10-14 days 2, 5

Special Considerations

ESBL-Producing Organisms

• Carbapenems (meropenem, imipenem) are first-line for ESBL-producing organisms 1
• Standard cephalosporins are ineffective against ESBL-producers 1

Antibiotic Resistance

• Local antibiogram data should guide empirical therapy choices 1
• Resistance to ampicillin and TMP/SMX has increased over the last 20 years 6
• E. coli resistance rates against cephalosporins, aminoglycosides, and nitrofurantoin remain relatively low 6

Imaging and Follow-up

• Renal and bladder ultrasound (RBUS) should be performed after the first febrile UTI 1
• Voiding cystourethrography (VCUG) is not recommended routinely after first UTI but indicated if RBUS reveals abnormalities 1
• Male infants under 12 months have higher risk of underlying urological abnormalities 1

Prevention of Recurrence

• Antibiotic prophylaxis may be considered in select cases with high-grade vesicoureteral reflux (VUR) or recurrent infections 1
• Long-term antibiotics may reduce the risk of repeat symptomatic UTI but must be weighed against increased risk of microbial resistance 7
• Parents should seek prompt medical evaluation (within 48 hours) for future febrile illnesses 1

Important Cautions

• Nitrofurantoin should not be used for febrile UTIs due to inadequate tissue concentrations for pyelonephritis, and is contraindicated in infants <4 months due to risk of hemolytic anemia 1
• Fluoroquinolones are generally not recommended in children due to safety concerns 1
• Trimethoprim-sulfamethoxazole is contraindicated in children less than 2 months of age 3, 4