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

Treatment of Urinary Tract Infections in Pediatric Patients

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

Initial Treatment Approach

Route of Administration

• Most children with UTIs can be treated with oral antibiotics 1
• Parenteral (IV) therapy should be used for children who:
  • Appear "toxic" or severely ill 1
  • Cannot retain oral intake including medications 1
  • Have uncertain compliance with obtaining or administering oral antibiotics 1
  • Are neonates or young infants under 3 months of age 2

Empiric Antibiotic Selection

For Oral Treatment:

• First-line options include:
  • Cephalosporins (cefixime, cefpodoxime, cefprozil, cefuroxime axetil, cephalexin) 1
  • Amoxicillin-clavulanate (20-40 mg/kg/day in 3 doses) 1
  • Trimethoprim-sulfamethoxazole (6-12 mg/kg trimethoprim and 30-60 mg/kg sulfamethoxazole per day in 2 doses) 1, 3

For Parenteral Treatment:

• Ceftriaxone (75 mg/kg every 24 hours) 1
• Cefotaxime (150 mg/kg per day, divided every 6-8 hours) 1
• Gentamicin (7.5 mg/kg per day, divided every 8 hours) 1
• Other options: ceftazidime, tobramycin, piperacillin 1

Age-Specific Considerations

• Neonates (<28 days): Hospitalize and treat with parenteral antibiotics (amoxicillin and cefotaxime) 2
• Infants 28 days to 3 months:
  • If clinically ill: Hospitalize with parenteral 3rd generation cephalosporin or gentamicin 2
  • If not acutely ill: May manage as outpatient with daily parenteral ceftriaxone or gentamicin until afebrile for 24 hours 2
• Children >3 months: Oral therapy appropriate if not toxic-appearing 1
• Children <2 months: Trimethoprim-sulfamethoxazole is contraindicated 3

Duration of Treatment

• Total course of therapy: 7-14 days 1
• Febrile UTIs/Pyelonephritis: 10-14 days 2, 4
• Cystitis: 5-7 days 2
• Important note: Shorter courses (1-3 days) have been shown to be inferior for febrile UTIs 1

Treatment Adjustments

• Adjust antibiotics based on urine culture and sensitivity results when available 1
• Consider local patterns of bacterial susceptibility when selecting empiric therapy 1
• Caution: Nitrofurantoin should not be used for febrile infants with UTIs as it may not achieve adequate serum/parenchymal concentrations to treat pyelonephritis 1

Follow-Up and Imaging

• Renal and bladder ultrasonography (RBUS) is recommended for febrile infants with confirmed UTIs 1
• RBUS should be performed to detect anatomic abnormalities that may require further evaluation 1
• Voiding cystourethrography (VCUG) should be considered after a second UTI 1

Special Considerations

• E. coli is the most common pathogen (approximately 85% of pediatric UTIs) 5
• Increasing antibiotic resistance has made amoxicillin alone a less acceptable choice 5
• For suspected or confirmed ESBL-producing organisms, consider amikacin as initial treatment 6
• Avoid treating asymptomatic bacteriuria as it may be harmful 1

Common Pitfalls to Avoid

• Using nitrofurantoin for febrile UTIs/pyelonephritis (inadequate tissue penetration) 1
• Treating for less than 7 days for febrile UTIs (associated with treatment failure) 1
• Failing to consider local antibiotic resistance patterns 1
• Not adjusting therapy based on culture results 1
• Treating asymptomatic bacteriuria 1