First-Line Treatment for Pediatric Urinary Tract Infections
For most children with UTI, oral antibiotics are equally effective as parenteral therapy and should be the preferred initial route of administration, with treatment duration of 7-14 days. 1
Route of Administration
Oral therapy is the first-line approach for most pediatric UTIs, as initiating treatment orally or parenterally is equally efficacious. 1
When to Use Parenteral Therapy:
- Children who appear "toxic" or severely ill 1
- Inability to retain oral intake (including medications) 1
- Concerns about compliance with obtaining or administering oral medications 1
- Neonates younger than 28 days should be hospitalized and receive parenteral therapy 2
First-Line Oral Antibiotic Options
The usual first-line choices for oral treatment include: 1
Recommended Oral Agents:
Cephalosporins (first-generation or third-generation):
Amoxicillin-clavulanate: 20-40 mg/kg per day in 3 doses 1
Trimethoprim-sulfamethoxazole (TMP-SMX): 6-12 mg/kg trimethoprim and 30-60 mg/kg sulfamethoxazole per day in 2 doses 1
First-Line Parenteral Antibiotic Options
For children requiring parenteral therapy: 1
- 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
Ceftriaxone is the recommended empirical choice for patients requiring intravenous therapy due to low resistance rates and clinical effectiveness. 1
Critical Considerations for Antibiotic Selection
Local Resistance Patterns:
The choice of empirical antibiotic MUST be based on local antimicrobial susceptibility patterns, particularly for TMP-SMX and cephalexin, as there is substantial geographic variability. 1 Adjust therapy according to sensitivity testing once available. 1
Agents to AVOID in Febrile UTI:
Nitrofurantoin should NOT be used to treat febrile infants with UTIs, as it does not achieve therapeutic concentrations in the bloodstream and parenchymal concentrations may be insufficient to treat pyelonephritis or urosepsis. 1 While nitrofurantoin is appropriate for uncomplicated cystitis in adults, this does not apply to febrile pediatric UTIs. 1
Treatment Duration
The total course of therapy should be 7 to 14 days, regardless of whether initial administration is oral or parenteral. 1 Evidence shows that 1- to 3-day courses for febrile UTIs are inferior; therefore, the minimum duration should be 7 days. 1
For children initially treated parenterally, switch to oral therapy once they exhibit clinical improvement (generally within 24-48 hours) and can retain oral fluids and medications. 1
Age-Specific Considerations
Neonates (<28 days):
Infants (28 days to 3 months):
- If clinically ill: hospitalize and use parenteral third-generation cephalosporin or gentamicin 2
- If not acutely ill: may manage as outpatient with daily parenteral ceftriaxone or gentamicin until afebrile for 24 hours, then complete 14 days with oral antibiotics 2
Children (>3 months):
- Most can be treated entirely with oral antibiotics 1, 3
- Treatment duration: 7-10 days for febrile UTI 3, 4
Common Pitfalls to Avoid
- Do not use nitrofurantoin for febrile UTI or suspected pyelonephritis in children, despite its utility in adult cystitis 1
- Do not select antibiotics without considering local resistance patterns, particularly for TMP-SMX where resistance can be substantial 1
- Do not use treatment courses shorter than 7 days for febrile UTI, as this is associated with inferior outcomes 1
- Do not routinely use broad-spectrum agents with antipseudomonal activity unless risk factors for nosocomial pathogens exist 1