Pediatric UTI Treatment
Immediate Treatment Approach
For most children with UTI, initiate oral antibiotic therapy for 7-14 days, reserving parenteral therapy only for toxic-appearing children, those unable to retain oral medications, or infants under 3 months of age. 1
First-Line Oral Antibiotic Selection
The preferred empiric oral antibiotics include: 1, 2
- Cephalosporins (cefixime, cefpodoxime, cefprozil, cefuroxime axetil, cephalexin) - most reliable coverage 1, 2
- Amoxicillin-clavulanate 1, 2
- Trimethoprim-sulfamethoxazole (TMP-SMX) - use with caution due to resistance rates of 19-63% in some regions 2, 3
Critical: Select empiric therapy based on local antibiotic resistance patterns, as E. coli resistance to TMP-SMX can exceed 60% in some areas. 1, 4
When to Use Parenteral Therapy
Initiate IV/IM antibiotics for: 1, 2
- Children appearing toxic or septic 1
- Inability to retain oral intake (vomiting) 1
- Age <3 months 5
- Uncertain compliance with oral medications 1
Ceftriaxone is the recommended parenteral choice due to low resistance rates and once-daily dosing. 6, 5
Treatment Duration by Clinical Presentation
Febrile UTI/Pyelonephritis
- Standard duration: 7-14 days total 1, 2
- Evidence shows 1-3 day courses are inferior for febrile UTIs 1, 2
- Some data suggest 5-9 days may be adequate for children >2 years, though evidence is not conclusive 1
Uncomplicated Cystitis (Lower UTI)
- Duration: 3-7 days 1
- Shorter courses (3-5 days) appear comparable to longer courses (7-14 days) for cystitis in children 1, 7
Critical Medication Contraindications
Never use nitrofurantoin for febrile UTIs or suspected pyelonephritis - it does not achieve adequate serum/parenchymal concentrations to treat upper tract infections. 1, 2 Nitrofurantoin is appropriate only for uncomplicated cystitis. 1
Avoid fluoroquinolones in children due to musculoskeletal safety concerns; reserve only for severe infections where benefits outweigh risks. 1
Age-Specific Treatment Algorithms
Neonates (<28 days)
- Hospitalize all neonates 5
- Parenteral amoxicillin + cefotaxime 5
- After 3-4 days of IV therapy with good response, switch to oral to complete 14 days total 5
Infants 28 days to 3 months
If clinically ill: 5
- Hospitalize with parenteral 3rd generation cephalosporin or gentamicin 5
- Switch to oral when afebrile for 24 hours to complete 14 days 5
If not acutely ill: 5
- May manage as outpatient with daily ceftriaxone or gentamicin until afebrile for 24 hours 5
- Complete 14 days with oral antibiotic 5
Children >3 months with Febrile UTI
- Oral therapy is appropriate if child is not toxic-appearing 1, 8
- 7-14 days of oral cephalosporin, amoxicillin-clavulanate, or TMP-SMX (if local resistance <20%) 1, 8
Monitoring and Follow-Up
Short-Term (1-2 Days)
Clinical reassessment within 24-48 hours is mandatory to confirm response to antibiotics and fever resolution. 1 If fever persists beyond 48 hours despite appropriate therapy, reevaluate for: 1, 2
Adjusting Therapy
- Always adjust antibiotics based on culture and sensitivity results when available 1, 8
- Most children should show clinical improvement within 24-48 hours of appropriate antibiotics 2
Imaging Recommendations
After First Febrile UTI
**Obtain renal and bladder ultrasound (RBUS) for all children <2 years with first febrile UTI** to detect anatomic abnormalities. 1, 2 For children >2 years, routine imaging after first uncomplicated UTI with good response is not indicated. 2
Voiding Cystourethrography (VCUG)
- NOT recommended routinely after first UTI 1, 2
- Perform VCUG after second febrile UTI 1, 2
- Consider after first UTI only if RBUS shows hydronephrosis, scarring, or findings suggesting high-grade VUR or obstruction 1, 2
Common Pitfalls to Avoid
- Using nitrofurantoin for any febrile UTI - inadequate tissue penetration for pyelonephritis 1, 2
- Treating for <7 days for febrile UTI - associated with higher recurrence rates 1, 2
- Failing to obtain urine culture before starting antibiotics - prevents culture-directed therapy 1
- Treating asymptomatic bacteriuria - leads to resistant organisms without clinical benefit 2
- Using bag specimens for culture in non-toilet-trained children - high contamination rate; use catheterization or suprapubic aspiration 1
- Ignoring local antibiotic resistance patterns - may result in treatment failure 1, 4
- Delaying treatment beyond 48 hours of fever onset - may increase risk of renal scarring 1
Antibiotic Prophylaxis
Routine prophylaxis is NOT recommended after first UTI. 1 Consider selective prophylaxis only for: 1
- Recurrent febrile UTIs 1
- High-grade vesicoureteral reflux (VUR grades IV-V) with recurrent infections 1
- Note: Prophylaxis reduces recurrence by ~50% but does not prevent renal scarring 1
When to Refer to Specialist
Refer for: 1