Treatment of Pediatric Urinary Tract Infections
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
First-Line Treatment Options
- Oral antibiotics are appropriate for most children with UTIs who are not toxic-appearing and can tolerate oral intake 1, 2
- First-line oral options include:
- Amoxicillin-clavulanate: 20-40 mg/kg per day in 3 divided doses 2
- Cephalosporins (cefixime, cefpodoxime, cefprozil, cefuroxime axetil, cephalexin) 2
- Trimethoprim-sulfamethoxazole (for children ≥2 months of age): 40 mg/kg sulfamethoxazole and 8 mg/kg trimethoprim per 24 hours, given in two divided doses every 12 hours 3, 4
Treatment Duration
- For cystitis: While optimal duration is not definitively established, shorter courses (3-5 days) appear comparable to longer courses (7-14 days) 5
- For pyelonephritis/febrile UTIs: Total treatment duration should be 7-14 days 1, 2
- For children >2 years with pyelonephritis: 5-9 days may be as effective as 10-14 days, though evidence is not conclusive 5
Special Considerations
- Parenteral therapy should be used for children who:
- Appear toxic
- Cannot retain oral intake
- Have uncertain compliance with oral antibiotics 1
- Nitrofurantoin should NOT be used for febrile UTIs/pyelonephritis as it does not achieve adequate serum concentrations to treat kidney infections 1, 2
- Adjust antibiotics based on urine culture and sensitivity results when available 1
- Consider local resistance patterns when selecting empiric therapy 2
Follow-Up and Imaging
- Renal and bladder ultrasonography (RBUS) is recommended for febrile infants with confirmed UTIs to detect anatomic abnormalities 1
- Voiding cystourethrography (VCUG) should be considered after a second UTI, not routinely after the first UTI 1
- Parents should seek prompt medical evaluation (within 48 hours) for future febrile illnesses to ensure that recurrent infections are detected and treated promptly 1
Common Pitfalls to Avoid
- Using nitrofurantoin for febrile UTIs/pyelonephritis 1, 2
- Treating febrile UTIs for less than 7 days 1, 2
- Failing to consider local antibiotic resistance patterns 2
- Not adjusting therapy based on culture results 1
- Treating asymptomatic bacteriuria 2
- Delaying treatment, as early antimicrobial treatment may decrease the risk of renal damage 1
Antibiotic Prophylaxis
- Continuous antibiotic prophylaxis (CAP) is generally not recommended for:
- Children with previous UTI
- Children with recurrent UTIs
- Children with vesicoureteral reflux (VUR) of any grade
- Children with isolated hydronephrosis
- Children with neurogenic bladder 6
- CAP may be considered in children with significant obstructive uropathies until surgical correction 6