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

Treatment for Pediatric Urinary Tract Infections

For pediatric urinary tract infections (UTIs), oral antibiotics for 7-14 days is the recommended first-line treatment for most children, with parenteral therapy reserved for toxic-appearing children or those unable to tolerate oral medications. 1

Initial Assessment and Diagnosis

• Significant bacteriuria in children is defined as ≥50,000 CFUs/mL of a single urinary pathogen (organisms like Lactobacillus, coagulase-negative staphylococci, and Corynebacterium are not considered clinically relevant) 1
• Proper specimen collection is essential for accurate diagnosis to avoid overdiagnosis and unnecessary treatment 1
• Treatment should only be initiated after confirmation of UTI through appropriate diagnostic criteria 1

Treatment Approach

Route of Administration

• Most children with UTI can be treated with oral antibiotics 1
• Parenteral therapy should be used for children who:
  • Appear clinically "toxic" 1
  • Are unable to retain oral intake including medications 1
  • Have uncertain compliance with oral medication regimens 1
  • Are neonates or young infants under 3 months 2

Antimicrobial Selection

First-line oral options:

• Cephalosporins (cefixime, cefpodoxime, cefprozil, cefuroxime axetil, cephalexin) 1
• Amoxicillin-clavulanate (20-40 mg/kg/day in 3 doses) 1
• Trimethoprim-sulfamethoxazole (40 mg/kg sulfamethoxazole and 8 mg/kg trimethoprim per 24 hours, divided every 12 hours) 1, 3, 4

First-line parenteral options:

• Ceftriaxone (75 mg/kg every 24 hours) 1
• Cefotaxime (150 mg/kg/day divided every 6-8 hours) 1
• Gentamicin (7.5 mg/kg/day divided every 8 hours) 1

Important considerations:

• Base antibiotic selection on local antimicrobial sensitivity patterns 1
• Adjust therapy according to sensitivity testing of the isolated pathogen 1
• Nitrofurantoin should NOT be used for febrile UTIs in infants as it doesn't achieve adequate serum concentrations to treat pyelonephritis 1
• For young infants (<3 months), parenteral antibiotics are recommended initially 2

Duration of Therapy

• 7-14 days is the recommended duration for UTI treatment in children 1
• Evidence shows that shorter courses (1-3 days) are inferior for febrile UTIs 1
• For cystitis (lower UTI), 5-7 days may be sufficient 2
• For pyelonephritis (upper UTI), 10-14 days is recommended 2, 5

Age-Specific Recommendations

Neonates (<28 days)

• Hospitalization with parenteral antibiotics (amoxicillin and cefotaxime) 2
• After 3-4 days of clinical improvement, complete 14 days with oral antibiotics 2

Infants (28 days to 3 months)

• If clinically ill: hospitalization with parenteral 3rd generation cephalosporin or gentamicin 2
• If not acutely ill: outpatient management with daily parenteral ceftriaxone or gentamicin until afebrile for 24 hours, then complete 14 days with oral antibiotics 2

Children >3 months

• Uncomplicated pyelonephritis: parenteral ceftriaxone or gentamicin until afebrile for 24 hours, then oral antibiotics to complete 10-14 days 2, 5
• Cystitis: oral antibiotics for 5-7 days 2

Follow-up and Imaging

• Renal and bladder ultrasonography (RBUS) is recommended for all young children with first febrile UTI 1
• The purpose of RBUS is to detect anatomic abnormalities requiring further evaluation 1
• Voiding cystourethrogram is not routinely needed after first UTI unless there are abnormal findings on ultrasound, atypical pathogens, complex clinical course, or known renal scarring 5

Common Pitfalls and Caveats

• Increasing antibiotic resistance is a major concern, particularly with E. coli producing extended-spectrum β-lactamases (ESBL) 6, 7
• Avoid overuse of 3rd generation cephalosporins in low-risk settings to prevent further resistance development 7
• Treatment of asymptomatic bacteriuria may be harmful and should be avoided 1
• Nitrofurantoin should not be used for febrile UTIs as it doesn't achieve adequate serum concentrations 1
• Amoxicillin alone is no longer recommended as first-line therapy due to increasing resistance 8