What is the management of Urinary Tract Infections (UTI) in pediatrics?

From the Guidelines

The management of urinary tract infections (UTIs) in pediatric patients should prioritize prompt diagnosis and appropriate antibiotic therapy, with a focus on preventing recurrent UTIs and renal scarring, as evidenced by the most recent guidelines and studies 1.

Key Considerations

• For uncomplicated UTIs in children, oral antibiotics such as amoxicillin-clavulanate or cephalexin are typically the first-line treatment, with a recommended course of 7-10 days 1.
• For febrile UTIs or pyelonephritis, a 10-14 day course of antibiotics is recommended, with initial parenteral therapy considered for infants under 3 months or severely ill children 1.
• Prophylactic antibiotics, such as trimethoprim-sulfamethoxazole, may be considered for recurrent UTIs, particularly in children with vesicoureteral reflux (VUR) or other underlying conditions 1.
• Imaging studies, including renal ultrasound and voiding cystourethrogram, are recommended to identify structural abnormalities and guide treatment decisions 1.

Treatment Approach

• The treatment approach should be individualized based on the child's age, symptoms, and underlying conditions, with a focus on preventing recurrent UTIs and renal scarring 1.
• The use of prophylactic antibiotics should be weighed against the risk of microbial resistance, and alternative approaches, such as behavioral modification and biofeedback, may be considered for children with bladder functional abnormalities 1.
• Surgery, including open, laparoscopic, or endoscopic procedures, may be reserved for high-grade VUR, recurrent UTI despite antibiotic prophylaxis, and noncompliance with prophylactic antibiotics 1.

Recent Guidelines and Studies

• The European Association of Urology/European Society of Paediatric Urology guidelines recommend a selective, risk-based approach to the use of prophylactic antibiotics in children with VUR, with a focus on preventing recurrent UTIs and renal scarring 1.
• The Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) trial demonstrated a decreased risk of recurrent UTIs in children receiving prophylactic antibiotics, particularly those with fever and bowel and bladder dysfunction 1.
• The American Academy of Pediatrics guidelines recommend prompt diagnosis and treatment of UTIs, with a focus on preventing recurrent UTIs and renal scarring, and emphasize the importance of individualized treatment decisions based on the child's age, symptoms, and underlying conditions 1.

From the FDA Drug Label

Cefixime for oral suspension and cefixime capsule is indicated in the treatment of adults and pediatric patients six months of age or older with uncomplicated urinary tract infections caused by susceptible isolates of Escherichia coli and Proteus mirabilis.

The management of Urinary Tract Infections (UTI) in pediatrics includes the use of cefixime for oral suspension or capsule in patients six months of age or older, for the treatment of uncomplicated UTIs caused by susceptible isolates of Escherichia coli and Proteus mirabilis 2.

• The treatment is specifically for uncomplicated UTIs, and the drug should be used only to treat infections that are proven or strongly suspected to be caused by susceptible bacteria.
• Local epidemiology and susceptibility patterns may contribute to the empiric selection of therapy in the absence of culture and susceptibility information.
• The dosage and administration of cefixime for pediatric patients is not explicitly stated in the provided text, but it is indicated that the drug can be used in pediatric patients six months of age or older.

From the Research

Diagnosis of Urinary Tract Infections (UTI) in Pediatrics

• UTI should be ruled out in preverbal children with unexplained fever and in older children with symptoms suggestive of UTI (dysuria, urinary frequency, hematuria, abdominal pain, back pain or new daytime incontinence) 3
• A midstream urine sample should be collected for urinalysis and culture in toilet-trained children; others should have urine collected by catheter or by suprapubic aspirate 3
• Urine culture with >104 colony forming units/mL is considered significant for the diagnosis of UTI in an infant if the clinical suspicion is strong 4
• Urine leukocyte esterase and nitrite can be used as an alternative screening test to urine microscopy in a child with suspected UTI 4

Management of UTI in Pediatrics

• Neonates younger than 28 days with a febrile UTI should be hospitalized, given supportive care and treated with parenteral amoxicillin and cefotaxime 5
• Infants from 28 days to 3 months who appear clinically ill with a febrile UTI should be hospitalized, receive supportive care and parenteral administration of a 3rd generation cephalosporin or gentamicin 5
• Children with complicated pyelonephritis should be hospitalized, receive supportive care and parenteral ceftriaxone or gentamicin each 24 hours until clinically improved and without fever for 24 hours 5
• Antibiotic treatment for seven to 10 days is recommended for febrile UTI 3
• Acute pyelonephritis can be treated with oral antibiotics in a non-toxic infant for 7-10 days 4
• Empiric treatment with cephalexin or nitrofurantoin would have been successful for almost all lower UTIs 6
• A second or third generation cephalosporin and amoxicillin-clavulanate are drugs of choice in the treatment of acute uncomplicated UTI 7

Treatment Duration and Follow-up

• The mean prescribed duration of antibiotic therapy was 8.3 days for patients with a lower UTI and 9.1 days for those with an upper UTI 6
• Children with cystitis who are only mildly symptomatic should be managed with supportive care until the result of the urine culture and sensitivity are available 5
• Children with cystitis who are moderately to severely symptomatic should receive an oral antibiotic and supportive care immediately 5
• If the therapy is effective, children with cystitis should show a good clinical response in 2 to 3 days 5
• Routine antimicrobial prophylaxis is rarely justified, but continuous antimicrobial prophylaxis should be considered for children with frequent febrile UTI 7