Treatment for Pediatric Urinary Tract Infections
The first-line treatment for pediatric UTIs includes oral cephalosporins (cephalexin 50-100 mg/kg/day divided in 4 doses or cefixime 8 mg/kg/day in 1 dose), amoxicillin-clavulanate, trimethoprim-sulfamethoxazole, or nitrofurantoin, with treatment duration of 5-7 days for uncomplicated UTI (cystitis) and 7-14 days for complicated UTI or pyelonephritis. 1
Age-Specific Treatment Approaches
Neonates (<28 days)
- Require hospitalization with parenteral antibiotics
- Initial therapy with parenteral antibiotics for 3-4 days
- Complete 14 days of therapy (transition to oral antibiotics after clinical improvement)
- Higher risk of congenital anomalies (10-20%) 1
Infants (28 days to 3 months)
- If clinically ill: hospitalization with parenteral antibiotics (3rd generation cephalosporin or gentamicin)
- If not acutely ill: can be managed as outpatients with daily parenteral antibiotics until afebrile for 24 hours
- Complete 14 days of therapy (transition to oral antibiotics after clinical improvement) 2
Older Children
- Uncomplicated cystitis:
- Oral antibiotics for 5-7 days
- Clinical improvement expected within 2-3 days 1
- Pyelonephritis:
- Complicated: Initial hospitalization with parenteral antibiotics
- Uncomplicated: Can be managed as outpatients with daily parenteral antibiotics until afebrile
- Complete 10-14 days of therapy 3
Antibiotic Selection
First-line options (per American Academy of Pediatrics) 1:
- Cephalexin: 50-100 mg/kg/day divided in 4 doses
- Cefixime: 8 mg/kg/day in 1 dose
- Amoxicillin-clavulanate
- Trimethoprim-sulfamethoxazole (for children ≥2 months)
- Nitrofurantoin
Important considerations:
- Avoid amoxicillin alone due to high resistance rates (75% of E. coli isolates) 1
- For trimethoprim-sulfamethoxazole in children ≥2 months: 40 mg/kg sulfamethoxazole and 8 mg/kg trimethoprim per 24 hours, divided in two doses every 12 hours 4
- Consider local resistance patterns when selecting antibiotics
- Obtain urine culture before starting antibiotics to guide therapy 1
Special Situations
Parenteral Therapy Indications:
- Age <2 months
- Toxic appearance
- Hemodynamically unstable
- Immunocompromised
- Unable to tolerate oral medication
- Not responding to oral antibiotics 5
Parenteral Options:
- Young infants: Combination of aminoglycoside/ampicillin or ceftazidime/ampicillin 6
- Older children: Third-generation cephalosporin or gentamicin 5
Follow-up and Prevention
Imaging Recommendations:
- Renal and bladder ultrasonography for all children with first febrile UTI 1, 3
- Consider voiding cystourethrography (VCUG) for recurrent UTIs or higher likelihood of vesicoureteral reflux 1
- DMSA renal scan 4-6 months after acute infection to evaluate for renal scarring in high-risk patients 1
Prevention Strategies:
- Ensure adequate hydration
- Address bowel and bladder dysfunction
- Promote proper hygiene practices
- Consider continuous antibiotic prophylaxis only for high-risk children (high-grade VUR or recurrent breakthrough febrile UTIs) 1
Clinical Pearls and Pitfalls
- Always obtain urine culture before starting antibiotics to guide therapy and confirm diagnosis 1
- Expect clinical improvement within 48-72 hours; reassess if not improving 1
- Diagnosis requires both pyuria and ≥50,000 CFUs/mL of a single pathogen in properly collected urine 1
- Increasing resistance to commonly used antibiotics is a concern; avoid indiscriminate antibiotic use 3
- Long-term follow-up is essential to identify predisposing abnormalities and monitor for renal scarring 1
- Instruct families to seek prompt medical care for future fevers to ensure timely treatment of potential recurrences 1