What is the first-line treatment for urinary tract infections (UTIs) in children?

First-Line Treatment for Urinary Tract Infections in Children

The first-line treatment for urinary tract infections in children includes oral cephalosporins, amoxicillin-clavulanate, or trimethoprim-sulfamethoxazole for 7-14 days, with the specific choice guided by local antimicrobial resistance patterns. 1, 2

Treatment Approach Based on Age and Clinical Presentation

Children <2 Months of Age

• Parenteral therapy is recommended for infants younger than 2 months with febrile UTI 3
• Hospitalization is typically required for this age group 3
• Trimethoprim-sulfamethoxazole is contraindicated in children less than 2 months of age 4, 5

Children >2 Months of Age

• Most children with UTI can be treated with oral antibiotics unless they appear toxic or cannot retain oral intake 1, 2
• First-line oral options include:
  • Cephalosporins (cefixime, cefpodoxime, cefprozil, cefuroxime axetil, cephalexin) 1, 2
  • Amoxicillin-clavulanate (20-40 mg/kg per day in 3 divided doses) 2
  • Trimethoprim-sulfamethoxazole (40 mg/kg sulfamethoxazole and 8 mg/kg trimethoprim per 24 hours, given in two divided doses every 12 hours) 4, 5

Duration of Therapy

• The recommended treatment duration is 7-14 days for febrile UTIs 1, 2
• Evidence shows that shorter courses (1-3 days) for febrile UTIs are inferior to longer courses 1
• For cystitis (lower UTI), a 5-7 day course is typically sufficient 3

Antibiotic Selection Considerations

• Local resistance patterns should guide empiric antibiotic choice 1, 2
• Escherichia coli is the most common pathogen, accounting for approximately 85% of UTIs in children 6, 7
• Resistance rates against ampicillin have increased over the last 20 years, making it a less acceptable choice 7, 8
• Avoid nitrofurantoin for febrile UTIs as it doesn't achieve adequate serum concentrations to treat pyelonephritis 1, 2

Special Considerations

• Parenteral therapy should be reserved for children who appear "toxic," children unable to retain oral intake, or cases where compliance with oral medication is uncertain 1
• Consider parenteral-to-oral switch therapy once clinical improvement occurs, typically within 24-48 hours 2
• Most children should show clinical improvement within 24-48 hours of starting appropriate antibiotics 1

Common Pitfalls to Avoid

• Treating asymptomatic bacteriuria may lead to selection of resistant organisms 1
• Using antibiotics with inadequate tissue penetration (like nitrofurantoin) for febrile UTIs 1, 2
• Failure to adjust therapy based on culture and sensitivity results 1
• Short courses (1-3 days) for febrile UTIs are inferior to 7-14 day courses 1, 2

Imaging Considerations

• Renal and bladder ultrasonography is recommended for all febrile infants with first UTI 1, 9
• Voiding cystourethrography (VCUG) is not routinely needed after first UTI unless abnormal renal/bladder ultrasound 1, 9
• In children with recurrent or complicated UTI, imaging of vesicoureteral reflux is usually appropriate 10