What are the management options for urinary tract infections (UTIs) in children and adults?

Management of Urinary Tract Infections in Children and Adults

The management of urinary tract infections (UTIs) should be based on patient age, clinical presentation, and local antimicrobial resistance patterns, with nitrofurantoin as first-line therapy for uncomplicated cystitis in adults and appropriate antimicrobial therapy for 7-14 days in children with their first febrile UTI. 1

Diagnosis

Adults

• Diagnosis requires both urinalysis showing pyuria and a urine culture with ≥50,000 CFUs/mL of a single pathogen 1
• Urinalysis alone is insufficient for definitive diagnosis 1
• Dipstick tests:
  • Leukocyte esterase: 72-97% sensitivity, 41-86% specificity 1
  • Nitrite: 19-48% sensitivity, 92-100% specificity 1
  • Combined leukocyte esterase or nitrite: 46-100% sensitivity, 42-98% specificity 1

Children

• For infants and children 2-24 months, diagnosis requires:
  • Pyuria on urinalysis AND
  • At least 50,000 CFUs/mL of a single pathogen in an appropriately collected specimen 1
• Collection methods:
  • Only catheterization or suprapubic aspiration specimens are suitable for culture in infants 1
  • Clean-catch specimens may be used in older children 2
• Microscopic urinalysis should follow a positive dipstick test 2

Treatment

Adults

Uncomplicated Cystitis

• First-line options:
  • Nitrofurantoin: 5-day course (clear recommendation) 1
  • Fosfomycin: single 3-g dose (clear recommendation) 1
  • Trimethoprim-sulfamethoxazole (TMP-SMX): 3-day course (clear recommendation) 1
  • Pivmecillinam: 3-day course (clear recommendation) 1
  • Fluoroquinolones: 3-day course (clear recommendation), but should be avoided if other options exist due to ecological and individual adverse effects 1, 3

Pyelonephritis

• First-line options:
  • β-lactams: 7-day course (clear recommendation) 1
  • Fluoroquinolones: 5-7 day course (clear recommendation) 1
  • For patients requiring IV therapy: ceftriaxone (recommended empirical choice) 1
  • TMP-SMX or first-generation cephalosporins are reasonable first-line agents depending on local resistance rates 1

Special Considerations for Older Adults

• Asymptomatic bacteriuria is common in older adults and should not be treated 1
• Clinical tools should be used to assess symptoms rather than testing for nondelirium behavioral changes or falls 1
• Avoid overtesting and overtreatment, especially in institutionalized individuals 1

Children

Febrile UTI/Pyelonephritis

• Antimicrobial therapy for 7-14 days 1
• Oral antibiotics are appropriate for non-toxic infants with acute pyelonephritis for 7-10 days 4
• Route of administration based on practical considerations (e.g., ability to retain oral fluids) 1
• First-line empiric options:
  • TMP-SMX: 40 mg/kg sulfamethoxazole and 8 mg/kg trimethoprim per 24 hours, divided every 12 hours 5
  • First-generation cephalosporins 1

Uncomplicated Lower UTI

• Short-course treatment (3-5 days) is sufficient 6
• Adjust antimicrobial therapy according to culture sensitivities 1

Follow-up and Imaging

Adults

• Imaging is not routinely recommended for uncomplicated UTIs 1
• Consider CT imaging if symptoms persist or worsen beyond 72 hours, or if concerns exist for kidney calculi, abscess, or alternative infection focus 1
• Ultrasonography is preferred for younger patients, pregnant women, and kidney transplant recipients 1

Children

• After first febrile UTI:
  • Renal and bladder ultrasound (RBUS) is recommended 1, 4
  • Voiding cystourethrogram (VCUG) is not routinely recommended after first UTI 1
• VCUG indications:
  • RBUS reveals hydronephrosis, scarring, or findings suggesting high-grade vesicoureteral reflux (VUR) or obstructive uropathy 1
  • Recurrent febrile UTI 1
  • Children under 2 years with non-E. coli UTI 4
• DMSA scan is indicated only in children with recurrent UTI and high-grade (3-5) VUR 4
• Parents should seek prompt medical evaluation (within 48 hours) for future febrile illnesses 1

Prevention of Recurrent UTI

Adults

• Diagnostic stewardship is essential to prevent unnecessary treatment of asymptomatic bacteriuria 1

Children

• Antibiotic prophylaxis is not indicated in children with normal urinary tract after UTI 4
• Prophylaxis is recommended for children with:
  • Bladder bowel dysfunction 4
  • High-grade VUR 4
  • Frequent symptomatic recurrences 6
• Prophylaxis should be discontinued if the child is toilet trained, free of bladder bowel dysfunction, and has not had a UTI in the past year 4

Common Pitfalls and Caveats

• Overtreatment of asymptomatic bacteriuria, especially in older adults, contributes to antimicrobial resistance 1
• Urine cultures with multiple organisms or colony counts <50,000 CFU/mL should be considered suspect and require confirmation 6
• Bagged urine specimens in children are unreliable and should not be used for culture 2
• Increasing antimicrobial resistance necessitates knowledge of local susceptibility patterns 3, 7
• Early treatment of pyelonephritis (within 48 hours of fever onset) reduces the risk of renal scarring 7
• Unnecessary antimicrobials can contribute to resistance and may increase the risk of UTI 1