Latest Guidelines for Acute Cystitis in Pediatrics
Nitrofurantoin is the first-line treatment for pediatric cystitis in children older than 2 months of age, administered for 3-5 days. 1
First-Line Antibiotic Selection
The American Academy of Pediatrics recommends nitrofurantoin as the preferred agent for uncomplicated cystitis in children >2 months old, demonstrating clinical cure rates of 88-93% and bacteriological cure rates of 81-92%. 1
Alternative First-Line Options:
- Amoxicillin-clavulanate is recommended by the World Health Organization as a first-choice option for young children with cystitis. 1
- Fosfomycin trometamol (single dose) is an appropriate alternative when nitrofurantoin is contraindicated. 1
- Trimethoprim-sulfamethoxazole can be used only if local E. coli resistance rates are <20%. 2, 1
Dosing Regimens for Oral Therapy:
- Nitrofurantoin: 5-7 mg/kg/day divided in 4 doses 2
- Amoxicillin-clavulanate: 20-40 mg/kg/day in 3 doses 2
- Trimethoprim-sulfamethoxazole: 6-12 mg/kg trimethoprim and 30-60 mg/kg sulfamethoxazole per day in 2 doses 2
- Cephalosporins (cefixime, cefpodoxime, cephalexin): Various dosing schedules available 2
Treatment Duration
Shorter courses of 3-5 days produce comparable outcomes to longer courses of 7-14 days for treating cystitis in children older than 2 months. 2, 1 This approach minimizes adverse effects and improves adherence. 1
The 2024 WikiGuidelines consensus found insufficient quality evidence to provide a definitive recommendation on exact duration, but multiple randomized trials support shorter courses when pyelonephritis likelihood is low. 2 Research demonstrates that 5-day treatment is adequate with 96% symptom resolution and only 1% bacteriological failure rate. 3
Route of Administration
Oral therapy is sufficient for uncomplicated cystitis in children who can tolerate oral medications. 2, 1 The 2011 AAP guidelines emphasize that initiating treatment orally or parenterally is equally efficacious, with route selection based on practical considerations. 2
Indications for Parenteral Therapy:
- Children appearing "toxic" 2
- Inability to retain oral intake or medications 2
- Uncertain compliance with oral administration 2
No data supports that initial parenteral treatment for cystitis is necessary in patients who can tolerate oral therapy. 2
Critical Pitfalls to Avoid
Never use amoxicillin or ampicillin for empirical treatment due to poor efficacy and very high worldwide resistance rates. 2, 1
Avoid fluoroquinolones as first-line therapy despite their high efficacy, as they should be reserved for important uses other than acute cystitis due to collateral damage and resistance promotion. 2, 1
Do not use nitrofurantoin when eGFR <30 mL/min as it becomes ineffective and potentially toxic in renal impairment. 1
Antibiotic Selection Based on Local Resistance
Empirical antibiotic selection must be based on local resistance patterns, with choices requiring <20% resistance rates for lower urinary tract infections. 1 The 20% resistance threshold for excluding empirical use is based on expert opinion from clinical, in vitro, and mathematical modeling studies. 2
Always adjust therapy according to susceptibility testing of the isolated uropathogen. 2
Special Considerations
Age-Specific Recommendations:
- Infants 2-24 months with febrile UTI: Requires different management approach than simple cystitis; 7-14 days of therapy recommended 2
- Children with cystitis only (afebrile): 3-5 day courses appropriate 2, 1
Patients with Allergies:
Nitrofurantoin or fosfomycin are appropriate alternatives for patients with penicillin and sulfa allergies. 1
Beta-Lactam Considerations:
Beta-lactams (except pivmecillinam) should be used with caution as they have inferior efficacy and more adverse effects compared to other UTI antimicrobials. 2 They are appropriate only when other recommended agents cannot be used. 2
Diagnostic Requirements
A urine culture and susceptibility test should always be performed when UTI is suspected, with treatment tailored based on the infecting uropathogen. 2 The appropriate threshold for "significant" bacteriuria in infants and children is ≥50,000 CFUs/mL of a single urinary pathogen. 2