Urinary Tract Infection (Pediatric) Management

Outpatient

Starting empiric treatment with a broad-spectrum antibiotic is recommended in a patient with presumptive UTI once a specimen for culture and urinalysis, preferably obtained from catheterization or suprapubic aspiration, is sent. The agent to be given should be based on the antibiotic susceptibility patterns of the infecting pathogen. Timely treatment with antibiotics decreases the severity of renal scarring. Local resistance patterns must be considered when choosing an antibiotic. Practicality should be considered when deciding which route of administration of treatment is to be chosen. Oral treatment has the same efficacy as that of parenterally administered therapies. Parenteral outpatient treatment may be administered to patients with acute pyelonephritis but does not require hospital admission.

Cephalosporins

First-, second-, and third-generation cephalosporins may be used in the treatment of urinary tract infection. Oral Cefixime has been shown to be cost-effective and efficacious.

Penicillins

Example drugs: Amoxicillin, Ampicillin, Co-amoxiclav

Co-amoxiclav may be a treatment option for acute uncomplicated urinary tract infections. Increasing resistance of E coli to Amoxicillin and Co-amoxiclav has been reported. Some sources advise against the use of Amoxicillin as first-line treatment.

Quinolones

Example drugs: Ciprofloxacin, Nalidixic acid

Quinolones provide excellent coverage against Gram-positive and Gram-negative organisms in the urinary tract. Drug-induced arthrotoxicity shown in animal models has discouraged use in children, although they may still be considered in the treatment of urinary tract infection.

Other Drugs

Co-trimoxazole

Co-trimoxazole may be used for S saprophyticus infection.

Nitrofurantoin

Nitrofurantoin is not considered adequate for pyelonephritis because of poor tissue penetration. This may be used to treat cystitis in older children.

Treatment Modification

Antibiotic treatment may need to be modified based on urine culture; however, changing antibiotics may not be necessary if clinical resolution occurs. If the patient’s condition does not improve after 24-48 hours of treatment, re-evaluation should be done.

Duration of Treatment

Urinary Tract Infection Pediatric_Management 2

Lower Urinary Tract Infection (UTI)/Cystitis

Short courses (2-4 days) of treatment may be equally effective as longer courses (7-14 days) for older patients.

Upper Urinary Tract Infection (UTI)/Acute Pyelonephritis

A 7–14-day course of antibiotics should be given to patients with upper urinary tract infection or acute pyelonephritis.

Inpatient

An immunocompromised patient or infant younger than 2 months is assumed to have acute pyelonephritis or complicated UTI and should be managed in the hospital.

Parenteral Antibiotic Therapy

Ampicillin or cephalosporin plus aminoglycoside (eg Gentamicin, Tobramycin) covers most urinary tract pathogens. Once-daily dosing is recommended for patients receiving aminoglycosides. Ampicillin provides coverage against Gram-positive cocci or Enterococcus. A third- or fourth-generation cephalosporin may be used as an alternative initial treatment when antimicrobial resistance is increasing or when there is concern about adverse reactions (eg nephrotoxicity). Examples of cephalosphorins are Ceftazidime, Cefotaxime, and Ceftriaxone. Co-amoxiclav may also be used. If intravenous (IV) treatment is not possible in a patient who requires parenteral therapy, then intramuscular (IM) treatment should be considered.

Shifting to Oral Antibiotic Therapy (Switch Therapy)

Parenteral treatment is given until the patient is clinically stable and afebrile for 48-72 hours. A short course of IV antibiotics followed by oral antibiotics is as effective as a longer duration of IV antibiotics.

Please see Pharmacological Therapy – Outpatient for options for oral antibiotic therapy.

Duration of Treatment

A 7-14-day course of antibiotics should be given to patients with upper urinary tract infection or acute pyelonephritis.

Antibiotic Prophylaxis

The goal of antibiotic prophylaxis is to prevent infection, renal damage, and scarring by sterilizing urine. Routine antibiotic prophylaxis in patients with first-time urinary tract infections is not recommended. Asymptomatic bacteriuria in a patient with a normal urinary tract is not an indication for antibiotic prophylaxis. Antibiotic prophylaxis may reduce the number of positive urine cultures but has not been clearly shown to reduce the number of new symptomatic UTI or new renal parenchymal defects.

Possible drawbacks of antibiotic prophylaxis are patient inconvenience, poor compliance, and colonization with resistant organisms. Prophylaxis may be considered in patients with a history of VUR, immunosuppressed, with partial urinary tract obstruction, or with recurrent UTI.

Antibiotics used for prophylaxis should ideally be administered orally and achieve high concentrations in the urine while maintaining low fecal concentrations. Antibiotics that may be used for prophylaxis are Co-trimoxazole, Nalidixic acid, Nitrofurantoin, cephalosporins, and fluoroquinolones.

Treatment of Vesicoureteral Reflux (VUR)

Not all cases of vesicoureteral reflux (VUR) require treatment. Intervention for VUR does not always prevent complications. Long-term antibiotic therapy may be given to prevent infections in a child who is expected to outgrow reflux. Correction of dysfunctional elimination (ie constipation) has been shown to decrease recurrent UTI. 

Hydration is important. Encourage adequate oral fluid intake. Give intravenous (IV) fluids if with signs of dehydration or reduced urine output. Advise voiding every 2-3 hours to prevent urinary stasis and bladder distention. Identify and manage any existing bladder or bowel dysfunction.

Patient and Parent Education

Advise on maintaining adequate hydration and continuing timed voiding schedules. Educate to complete the antibiotics. Counsel on the importance of promptly seeking medical evaluation for febrile illnesses, especially in patients with recurrent UTIs. Advise on prompt recognition of symptoms, treatment options, prevention, and prognosis.