First-Line Treatment for Paediatric Cystitis
Nitrofurantoin is the recommended first-line treatment for paediatric cystitis in children older than 2 months of age, based on its proven efficacy, safety profile, and ability to preserve broader-spectrum antibiotics for more serious infections. 1
Primary Treatment Options
Nitrofurantoin (Preferred First-Line Agent)
- Dosing: 100 mg twice daily for 5 days in older children (dose-adjusted for younger children based on weight) 1
- Demonstrates clinical cure rates of 88-93% and bacteriological cure rates of 81-92% 2
- Preserves systemically active agents for treating other infections, reducing antimicrobial resistance pressure 1
- Should be avoided when eGFR <30 mL/min due to reduced efficacy and increased toxicity risk 3
Alternative First-Line Options
- Trimethoprim-sulfamethoxazole (TMP/SMX): 3-day course is reasonable when local resistance rates are <20% 1, 2
- Amoxicillin-clavulanate: Recommended by WHO as a first-choice option, particularly for young children 1
- Fosfomycin trometamol: 3 g single dose is appropriate when nitrofurantoin is contraindicated 1, 3
Treatment Duration
Shorter courses (3 to 5 days, depending on the antimicrobial used) produce comparable outcomes to longer courses (7 to 14 days) and are reasonable for treating cystitis in children older than 2 months when pyelonephritis is unlikely. 1
- 5-day courses with nitrofurantoin are effective and well-supported 4
- The evidence base shows heterogeneity in trial design, making a definitive duration recommendation challenging, but shorter courses minimize adverse effects and improve adherence 1
Key Clinical Considerations
When to Use Oral vs. Parenteral Therapy
- Oral therapy is sufficient for uncomplicated cystitis in children who can tolerate oral medications 1
- No data supports initial parenteral treatment for cystitis in patients tolerating oral therapy 1
- A single parenteral dose of an aminoglycoside may be a reasonable alternative based on observational studies 1
Antibiotic Selection Framework
- Selection should be based on local resistance patterns, with empirical choices requiring <20% resistance rates for lower urinary tract infections 1
- Antibiotics must achieve adequate urinary concentrations and provide reliable activity against common pathogens (primarily E. coli, Proteus, Klebsiella, S. saprophyticus) 1, 5
- Consider patient age, severity of symptoms, and presence of complicating factors 6
Common Pitfalls to Avoid
Inappropriate Antibiotic Choices
- Do not use amoxicillin or ampicillin for empiric treatment due to poor efficacy and high resistance rates (median 75% E. coli resistance globally) 1, 2
- Avoid fluoroquinolones as first-line therapy despite high efficacy, as they promote resistance and should be reserved for situations where alternatives cannot be used 1, 2
- Beta-lactams alone (without clavulanate) have inferior efficacy and should not be first-line 7
Treatment Duration Errors
- Avoid unnecessarily prolonged courses (>7 days) for uncomplicated cystitis, as shorter courses are equally effective 1, 4
- Do not assume all UTIs require 10-14 days of therapy; this duration is reserved for pyelonephritis 8, 5
Diagnostic Considerations
- Urine culture is not routinely necessary for straightforward cystitis with typical symptoms 2, 7
- Obtain urine culture when: symptoms persist or recur within 2-4 weeks, pyelonephritis is suspected, or the patient has complicating factors 2, 7
- Routine follow-up visits may not be necessary if bacteria are sensitive to prescribed antibiotics and symptoms resolve 4
Special Populations
Infants Under 3 Months
- Require different management with parenteral therapy (ceftriaxone or gentamicin) and hospitalization for febrile UTIs 8, 6
- Complete 14 days of therapy for this age group 8
Patients with Renal Impairment
- Switch to fosfomycin when eGFR <30 mL/min, as nitrofurantoin becomes ineffective and potentially toxic 3
- Fosfomycin provides adequate urinary concentrations without dose adjustment 3