What is the treatment for Urinary Tract Infections (UTIs) in children?

Treatment of Urinary Tract Infections in Children

Most children with UTIs can be treated effectively with oral antibiotics for 7-14 days, with first-line options including cephalosporins (cefixime, cefpodoxime, cefprozil, cefuroxime axetil, cephalexin), amoxicillin-clavulanate, or trimethoprim-sulfamethoxazole, guided by local resistance patterns. 1, 2, 3

Initial Treatment Selection

Oral Therapy (First-Line for Most Children)

The American Academy of Pediatrics recommends oral antibiotics as the standard approach unless specific contraindications exist. 1, 2

• Cephalosporins are first-line options and include cefixime, cefpodoxime, cefprozil, cefuroxime axetil, and cephalexin 1, 2, 3
• Amoxicillin-clavulanate at 20-40 mg/kg per day divided into 3 doses is an excellent alternative 2, 3
• Trimethoprim-sulfamethoxazole at 40 mg/kg sulfamethoxazole and 8 mg/kg trimethoprim per 24 hours in two divided doses, but use with caution due to E. coli resistance rates of 19-63% in some regions 1, 4, 5

When to Use Parenteral Therapy

Reserve IV antibiotics for these specific situations only: 1, 2, 3

• Child appears "toxic" or severely ill 1
• Unable to retain oral intake or medications 1
• Uncertain compliance with oral medications 1
• Age less than 2-3 months (higher complication risk) 2

Treatment Duration

The standard treatment duration is 7-14 days for febrile UTIs/pyelonephritis, regardless of whether you start with IV or oral therapy. 1, 2, 3

• Short courses of 1-3 days for febrile UTIs are inferior and should be avoided 1, 2, 3
• For simple cystitis in older children, 5-7 days may be sufficient 6
• Once-daily IV dosing (such as ceftriaxone or gentamicin) allows for outpatient day treatment center management until afebrile for 24 hours, then switch to oral 7

Critical Antibiotic Selection Considerations

What to Avoid

• Never use nitrofurantoin for febrile UTIs as it does not achieve adequate serum concentrations to treat pyelonephritis 1, 2, 3
• Nitrofurantoin is acceptable only for lower UTI/cystitis 8
• Avoid trimethoprim-sulfamethoxazole in infants <6 weeks due to hepatic injury risk 2
• Avoid nitrofurantoin before 4 months of age due to hemolytic anemia risk 2
• Do not use in children <2 months of age per FDA labeling 4, 5

Resistance Pattern Guidance

• Base your empiric choice on local uropathogens resistance data 1, 2, 3
• E. coli resistance to ampicillin and trimethoprim-sulfamethoxazole has increased significantly over the past 20 years 9
• Cephalosporins, aminoglycosides, and nitrofurantoin (for cystitis only) maintain relatively low resistance rates 9

Monitoring Treatment Response

Expect clinical improvement within 24-48 hours of starting appropriate antibiotics. 1, 2, 3

• If no improvement by 48 hours, this constitutes an "atypical" UTI requiring further evaluation 1
• Switch from parenteral to oral therapy once clinical improvement occurs, typically within 24-48 hours 2, 3
• Adjust therapy based on culture and sensitivity results when available 1, 3

Imaging Recommendations

When to Image

• Renal and bladder ultrasonography is recommended for all febrile infants with first UTI to detect anatomic abnormalities 1, 2, 3
• Routine imaging is NOT indicated for first uncomplicated febrile UTI with good response in children >2 years 1

Indications for Imaging

Image if any of these features are present: 1

• Poor response to antibiotics within 48 hours

• Sepsis or seriously ill appearance

• Poor urine stream

• Elevated creatinine

• Non-E. coli organism

• Recurrent UTI

• Voiding cystourethrography (VCUG) is not routinely needed after first UTI unless ultrasound shows abnormalities or there is recurrent febrile UTI 1, 2, 3

Antibiotic Prophylaxis

Continuous antibiotic prophylaxis (CAP) is NOT recommended for most children, including those with previous UTI, recurrent UTIs, vesicoureteral reflux of any grade, isolated hydronephrosis, or neurogenic bladder. 10

• CAP may benefit only select high-risk children with VUR: uncircumcised males, bladder/bowel dysfunction, and high-grade reflux 2
• When used, prophylactic antibiotics include trimethoprim-sulfamethoxazole, amoxicillin, or nitrofurantoin at quarter to half therapeutic dose 2
• CAP is suggested only in children with significant obstructive uropathies until surgical correction 10
• The emergence of antimicrobial resistance is a proven risk with CAP, and it shows no effect on preventing complications 10

Common Pitfalls to Avoid

• Do not treat asymptomatic bacteriuria as this leads to selection of resistant organisms 1, 3
• Do not use antibiotics with inadequate tissue penetration (nitrofurantoin) for febrile UTIs 1, 2, 3
• Do not fail to adjust therapy based on culture and sensitivity results 1, 3
• Do not use short 1-3 day courses for febrile UTIs 1, 2, 3
• Avoid surveillance urine cultures in asymptomatic patients 2

Age-Specific Considerations

Neonates (<28 days)

• Hospitalize and treat with parenteral ampicillin plus cefotaxime 6
• Complete 14 days total therapy, switching to oral after 3-4 days of good response 6

Young Infants (28 days to 3 months)

• If clinically ill: hospitalize with parenteral third-generation cephalosporin or gentamicin 6, 9
• If not acutely ill: outpatient management with daily parenteral ceftriaxone or gentamicin until afebrile 24 hours 6
• Complete 14 days total therapy 6

Older Children (>3 months)

• Uncomplicated pyelonephritis: outpatient oral third-generation cephalosporin for 10-14 days 6, 9
• Complicated pyelonephritis: hospitalize with parenteral therapy until improved and afebrile 24 hours, then oral to complete 10-14 days 6
• Cystitis: oral antibiotics for 5-7 days if moderately to severely symptomatic 6