Recommended Treatment for Pediatric Urinary Tract Infections (UTI)
For pediatric urinary tract infections, oral antibiotics for 7-14 days are recommended as first-line treatment, with specific choices including amoxicillin-clavulanate, cephalosporins, or trimethoprim-sulfamethoxazole, guided by local resistance patterns. 1
Treatment Selection Algorithm
First-Line Oral Treatment Options
- Amoxicillin-clavulanate: 20-40 mg/kg per day in 3 divided doses 1
- Cephalosporins (cefixime, cefpodoxime, cefprozil, cefuroxime axetil, cephalexin) 1
- Trimethoprim-sulfamethoxazole: 40 mg/kg sulfamethoxazole and 8 mg/kg trimethoprim per 24 hours, given in two divided doses every 12 hours 2
- Note: Not recommended for infants less than 2 months of age 2
Treatment Duration
Route of Administration
- Most children with UTI can be treated with oral antibiotics unless they appear toxic or cannot retain oral intake 1
- Consider parenteral-to-oral switch therapy once clinical improvement occurs, typically within 24-48 hours 1
Special Populations
Neonates (<28 days)
- Hospitalization required with parenteral antibiotics (amoxicillin and cefotaxime) 3
- Complete 14 days of therapy, transitioning to oral antibiotics after 3-4 days of good response to parenteral treatment 3
Infants (28 days to 3 months)
- If clinically ill: Hospitalization with parenteral 3rd generation cephalosporin or gentamicin 3
- If not acutely ill: Outpatient management possible with parenteral ceftriaxone or gentamicin until afebrile for 24 hours 3
- Complete 14 days of therapy with oral antibiotics 3
Treatment Based on UTI Type
Pyelonephritis/Febrile UTI
- Complicated cases: Initial parenteral therapy until clinically improved and afebrile for 24 hours 3
- Uncomplicated cases: Outpatient parenteral ceftriaxone or gentamicin until afebrile for 24 hours, then complete 10-14 days with oral antibiotics 3
- Avoid nitrofurantoin as it does not achieve adequate serum concentrations to treat pyelonephritis 1
Cystitis
- Mildly symptomatic: Supportive care until culture results available 3
- Moderately to severely symptomatic: Immediate oral antibiotics for 5-7 days 3, 4
- A 2-4 day course of oral antibiotics may be as effective as 7-14 days for uncomplicated lower UTIs 4
Important Considerations
Antibiotic Selection Factors
- Base choice on local resistance patterns of common uropathogens 1
- Consider patient's clinical status and previous culture results if available 1
- For empirical treatment of pyelonephritis, trimethoprim-sulfamethoxazole or a first-generation cephalosporin are reasonable first-line agents, depending on local resistance rates 5
Monitoring and Follow-up
- Consider renal and bladder ultrasonography for first febrile UTI to detect anatomical abnormalities 1, 5
- Avoid surveillance urine cultures in asymptomatic patients 1
Common Pitfalls to Avoid
- Do not use antibiotics that only achieve urinary concentrations (like nitrofurantoin) for febrile UTIs 1
- Do not treat asymptomatic bacteriuria 1
- Avoid short courses (1-3 days) for febrile UTIs as they are inferior to 7-14 day courses 1
- Avoid ciprofloxacin as first-line therapy in children due to increased incidence of adverse events, particularly related to joints and surrounding tissues 6
Antibiotic Prophylaxis
- May benefit select high-risk children with vesicoureteral reflux (VUR), including uncircumcised males, those with bladder and bowel dysfunction, and high-grade reflux 1
- Common prophylactic antibiotics include trimethoprim-sulfamethoxazole, amoxicillin, and nitrofurantoin at quarter to half of therapeutic dose 1, 7