Pediatric Urinary Tract Infection Medication
- Author: Donna J Fisher, MD; Chief Editor: Russell W Steele, MD more...
Medication Summary
Antibiotics are used to treat urinary tract infection (UTI) and to prevent its recurrence. Avoid nephrotoxic drugs whenever possible. On occasion, analgesic therapy may be used to provide relief because of voiding symptoms.
Start antibiotics after urinalysis and culture are obtained in patients with UTI. A 10-day course of antibiotics is recommended, even for an uncomplicated infection. Typical short-course treatments should be reserved for nontoxic-appearing adolescent females with UTI. Be aware of increasing rates of antibiotic resistance and the need to choose antibiotic therapy accordingly.
If the urinalysis is positive for nitrites, the bacterium responsible for the infection is exceedingly likely to be sensitive to a third-generation cephalosporin. However, the 8+% resistance of nitrite-positive organisms to first-generation oral cephalosporins limits their use.[36]
Empiric antibiotics should be chosen for coverage of the most common uropathogens; namely, E coli and Enterococcus, Proteus, and Klebsiella species. For suspected pyelonephritis, parenteral antibiotics are recommended.
Evidence indicates that oral antibiotics are adequate therapy for febrile UTIs in young infants and children; short-term (fever) and long-term (renal scarring) outcomes are comparable to those that occur with parenteral therapy.
The possibility of antibiotic resistance must be considered when choosing empiric therapy, especially with ampicillin. Knowledge of the local antibiotic resistance helps in guiding antibiotic choice.
Antibiotic agents
Class Summary
Antibiotics are used to treat bacterial infections of the urinary tract. Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Ceftriaxone (Rocephin)
This agent is used for initial parenteral therapy for complicated pyelonephritis in pediatric patients beyond the neonatal period. It is indicated for urinary tract infections caused by E coli, Proteus mirabilis, Morganella morganii, P vulgaris, or K pneumoniae.
Cefotaxime (Claforan)
Cefotaxime is used as the initial parenteral therapy for pediatric patients with acute complicated pyelonephritis. It may be used for neonates or jaundiced patients. In infants, a 2- to 8-week regimen also includes ampicillin. A dose every 6-8 hours is required.
Ampicillin (Marcillin, Omnipen, Polycillin)
Ampicillin is a parenteral therapy for the initial treatment of patients with acute pyelonephritis or with gram-positive cocci in urinary sediment or when no organisms are observed. It is indicated for urinary tract infections caused by E coli and P mirabilis.
Amoxicillin and clavulanate (Augmentin)
This is an oral therapy for completion of initial treatment of infection with a susceptible organism. Amoxicillin inhibits bacterial cell-wall synthesis by binding to penicillin-binding proteins. The addition of clavulanate inhibits beta-lactamase producing bacteria.
This is a good alternative antibiotic for patients who are allergic or have an intolerance to the macrolide class. It is usually well tolerated and provides good coverage against most infectious agents. It is not effective against Mycoplasma and Legionella species. The half-life of the oral dosage form is 1-1.3 hours. This treatment has good tissue penetration but does not enter the cerebrospinal fluid (CSF).
For patients over age 3 months, base the dosing protocol on the amoxicillin content. Because of different amoxicillin-clavulanic acid ratios in the 250mg tablet (250-125) versus the 250mg chewable tablet (250-62.5), do not use the 250mg tablet until the child weighs over 40kg. The amoxicillin and clavulanate combination is also available as an oral suspension for children.
Gentamicin (Garamycin)
This is the initial parenteral therapy for patients with bacterial pyelonephritis who are allergic to cephalosporins. For complicated UTIs, it is sometimes used in combination with a cephalosporin.
Sulfamethoxazole and trimethoprim (Bactrim, Cotrim, Septra)
This is an oral treatment for bacterial urinary tract infection and for prevention of reinfection. It is available in oral tablet or suspension form.
Cephalexin (Biocef, Cefanex, Keflex)
Cephalexin is a first-generation cephalosporin. This is an oral treatment for bacterial UTI and for prevention of infection in infants younger than 6-8 weeks.
Cefixime (Suprax)
Cefixime is a third-generation cephalosporin. It is an oral treatment for acute bacterial urinary tract infection. By binding to 1 or more penicillin-binding proteins, it arrests bacterial cell-wall synthesis and inhibits bacterial growth.
Cefpodoxime (Vantin)
Cefpodoxime is a third-generation cephalosporin. It is an oral treatment for acute bacterial UTI. It is indicated for the management of infections caused by susceptible mixed aerobic-anaerobic microorganisms.
Nitrofurantoin (Furadantin, Macrobid, Macrodantin)
This is an oral treatment for bacterial lower UTI (cystitis) and for the prevention of reinfection. Nitrofurantoin is a synthetic nitrofuran that interferes with bacterial carbohydrate metabolism by inhibiting acetylcoenzyme A. It is bacteriostatic at low concentrations (5-10 mcg/mL) and is bactericidal at higher concentrations.
Trimethoprim (Proloprim, Trimpex)
Trimethoprim is an oral antibiotic used for the prevention of UTI. It is a dihydrofolate reductase inhibitor that prevents the production of tetrahydrofolic acid in bacteria. It is active in vitro against a broad range of gram-positive and gram-negative bacteria, including uropathogens; eg, Enterobacteriaceae and Staphylococcus saprophyticus.
Resistance is usually mediated by decreased cell permeability or by alterations in the structure or amount of dihydrofolate reductase. Trimethoprim demonstrates synergy with sulfonamides, potentiating inhibition of bacterial tetrahydrofolate production.
Ciprofloxacin (Cipro, Cipro XR)
This is a fluoroquinolone that inhibits bacterial deoxyribonucleic acid (DNA) synthesis and, consequently, growth by inhibiting DNA gyrase and topoisomerases, which are required for replication, transcription, and translation of genetic material. Quinolones have broad activity against gram-positive and gram-negative aerobic organisms. Ciprofloxacin has no activity against anaerobes. Continue treatment for at least 2 days (7-14d typical) after signs and symptoms have disappeared.
Analgesics
Class Summary
These agents are used to provide relief from voiding symptoms due to urinary tract infection.
Acetaminophen (Tylenol, Panadol, Tempra)
Acetaminophen is a nonopioid, systemic analgesic used for moderate voiding discomfort caused by urinary tract infection.
Ibuprofen (Motrin, Advil)
Ibuprofen is a nonsteroidal anti-inflammatory agent that is used to provide symptomatic relief of dysuria.
Urinary bladder analgesics
Class Summary
These agents are used to relieve burning, spasticity, and pain during voiding due to urinary tract infection.
Phenazopyridine (Azo-Standard, Pyridium, Urodine)
Phenazopyridine exerts local, topical anesthetic or analgesic action on urinary mucosa. It is used for symptomatic relief of pain, burning, urgency, frequency, and other discomforts arising from irritation of the lower urinary tract mucosa caused by infection, trauma, surgery, endoscopic procedures, passage of sound, or catheters. Analgesic action may reduce or eliminate the need for systemic analgesics.
Zaffanello M, Malerba G, Cataldi L, Antoniazzi F, Franchini M, Monti E, et al. Genetic risk for recurrent urinary tract infections in humans: a systematic review. J Biomed Biotechnol. 2010;2010:321082. [Medline]. [Full Text].
Hoberman A, Chao HP, Keller DM, Hickey R, Davis HW, Ellis D. Prevalence of urinary tract infection in febrile infants. J Pediatr. Jul 1993;123(1):17-23. [Medline].
Zorc JJ, Levine DA, Platt SL, Dayan PS, Macias CG, Krief W, et al. Clinical and demographic factors associated with urinary tract infection in young febrile infants. Pediatrics. Sep 2005;116(3):644-8. [Medline].
Shaikh N, Morone NE, Lopez J, Chianese J, Sangvai S, D'Amico F, et al. Does this child have a urinary tract infection?. JAMA. Dec 26 2007;298(24):2895-904. [Medline].
[Guideline] Subcommittee on Urinary Tract Infection; Steering Committee on Quality Improvement and Management. Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months. Pediatrics. Aug 28 2011;[Medline].
Girardet P, Frutiger P, Lang R. Urinary tract infections in pediatric practice. A comparative study of three diagnostic tools: dip-slides, bacterioscopy and leucocyturia. Paediatrician. 1980;9(5-6):322-37. [Medline].
Goldsmith BM, Campos JM. Comparison of urine dipstick, microscopy, and culture for the detection of bacteriuria in children. Clin Pediatr (Phila). Apr 1990;29(4):214-8. [Medline].
Anderson JD, Chambers GK, Johnson HW. Application of a leukocyte and nitrite urine test strip to the management of children with neurogenic bladder. Diagn Microbiol Infect Dis. Jul 1993;17(1):29-33. [Medline].
Craver RD, Abermanis JG. Dipstick only urinalysis screen for the pediatric emergency room. Pediatr Nephrol. Jun 1997;11(3):331-3. [Medline].
Shaw KN, McGowan KL, Gorelick MH, Schwartz JS. Screening for urinary tract infection in infants in the emergency department: which test is best?. Pediatrics. Jun 1998;101(6):E1. [Medline].
Anad FY. A simple method for selecting urine samples that need culturing. Ann Saudi Med. Jan-Mar 2001;21(1-2):104-5. [Medline].
Bachur R, Harper MB. Reliability of the urinalysis for predicting urinary tract infections in young febrile children. Arch Pediatr Adolesc Med. Jan 2001;155(1):60-5. [Medline].
[Best Evidence] Lunn A, Holden S, Boswell T, Watson AR. Automated microscopy, dipsticks and the diagnosis of urinary tract infection. Arch Dis Child. Mar 2010;95(3):193-7. [Medline].
Smolkin V, Koren A, Raz R, Colodner R, Sakran W, Halevy R. Procalcitonin as a marker of acute pyelonephritis in infants and children. Pediatr Nephrol. Jun 2002;17(6):409-12. [Medline].
Nikfar R, Khotaee G, Ataee N, Shams S. Usefulness of procalcitonin rapid test for the diagnosis of acute pyelonephritis in children in the emergency department. Pediatr Int. Jul 6 2009;[Medline].
Bressan S, Andreola B, Zucchetta P, Montini G, Burei M, Perilongo G, et al. Procalcitonin as a predictor of renal scarring in infants and young children. Pediatr Nephrol. Jun 2009;24(6):1199-204. [Medline].
Ipek IO, Sezer RG, Kinay ES, et al. Relationship between procalcitonin levels and presence of vesicoureteral reflux during first febrile urinary tract infection in children. Urology. Jan 12 2012;[Medline].
Quigley R. Diagnosis of urinary tract infections in children. Curr Opin Pediatr. Apr 2009;21(2):194-8. [Medline].
Lin DS, Huang FY, Chiu NC, Koa HA, Hung HY, Hsu CH, et al. Comparison of hemocytometer leukocyte counts and standard urinalyses for predicting urinary tract infections in febrile infants. Pediatr Infect Dis J. Mar 2000;19(3):223-7. [Medline].
Lin DS, Huang SH, Lin CC, Tung YC, Huang TT, Chiu NC, et al. Urinary tract infection in febrile infants younger than eight weeks of Age. Pediatrics. Feb 2000;105(2):E20. [Medline].
Pennesi M, L'erario I, Travan L, et al. Managing children under 36 months of age with febrile urinary tract infection: a new approach. Pediatr Nephrol. Jan 11 2012;[Medline].
Merguerian PA, Sverrisson EF, Herz DB, McQuiston LT. Urinary tract infections in children: recommendations for antibiotic prophylaxis and evaluation. An evidence-based approach. Curr Urol Rep. Mar 2010;11(2):98-108. [Medline].
Downs SM. Technical report: urinary tract infections in febrile infants and young children. The Urinary Tract Subcommittee of the American Academy of Pediatrics Committee on Quality Improvement. Pediatrics. Apr 1999;103(4):e54. [Medline].
Paschke AA, Zaoutis T, Conway PH, Xie D, Keren R. Previous antimicrobial exposure is associated with drug-resistant urinary tract infections in children. Pediatrics. Apr 2010;125(4):664-72. [Medline].
Schnadower D, Kuppermann N, Macias CG, et al. Febrile infants with urinary tract infections at very low risk for adverse events and bacteremia. Pediatrics. Dec 2010;126(6):1074-83. [Medline].
Schnadower D, Kuppermann N, Macias CG, et al. Sterile Cerebrospinal Fluid Pleocytosis in Young Febrile Infants With Urinary Tract Infections. Arch Pediatr Adolesc Med. Jul 2011;165(7):635-641. [Medline].
Hoberman A, Keren R. Antimicrobial prophylaxis for urinary tract infection in children. N Engl J Med. Oct 29 2009;361(18):1804-6. [Medline].
Montini G, Rigon L, Zucchetta P, Fregonese F, Toffolo A, Gobber D, et al. Prophylaxis after first febrile urinary tract infection in children? A multicenter, randomized, controlled, noninferiority trial. Pediatrics. Nov 2008;122(5):1064-71. [Medline].
Garin EH, Olavarria F, Garcia Nieto V, Valenciano B, Campos A, Young L. Clinical significance of primary vesicoureteral reflux and urinary antibiotic prophylaxis after acute pyelonephritis: a multicenter, randomized, controlled study. Pediatrics. Mar 2006;117(3):626-32. [Medline].
Pennesi M, Travan L, Peratoner L, Bordugo A, Cattaneo A, Ronfani L, et al. Is antibiotic prophylaxis in children with vesicoureteral reflux effective in preventing pyelonephritis and renal scars? A randomized, controlled trial. Pediatrics. Jun 2008;121(6):e1489-94. [Medline].
Mattoo TK. Are prophylactic antibiotics indicated after a urinary tract infection?. Curr Opin Pediatr. Apr 2009;21(2):203-6. [Medline]. [Full Text].
Craig JC, Simpson JM, Williams GJ, Lowe A, Reynolds GJ, McTaggart SJ, et al. Antibiotic prophylaxis and recurrent urinary tract infection in children. N Engl J Med. Oct 29 2009;361(18):1748-59. [Medline].
Williams G, Craig JC. Long-term antibiotics for preventing recurrent urinary tract infection in children. Cochrane Database Syst Rev. Mar 16 2011;3:CD001534. [Medline].
Ferrara P, Romaniello L, Vitelli O, Gatto A, Serva M, Cataldi L. Cranberry juice for the prevention of recurrent urinary tract infections: a randomized controlled trial in children. Scand J Urol Nephrol. 2009;43(5):369-72. [Medline].
Hoberman A, Wald ER, Hickey RW, Baskin M, Charron M, Majd M, et al. Oral versus initial intravenous therapy for urinary tract infections in young febrile children. Pediatrics. Jul 1999;104(1 Pt 1):79-86. [Medline].
Weisz D, Seabrook JA, Lim RK. The Presence of Urinary Nitrites Is a Significant Predictor of Pediatric Urinary Tract Infection Susceptibility to First- and Third-Generation Cephalosporins. J Emerg Med. Jul 2010;39(1):6-12.
- Table 1. Urinalysis for Presumptive Diagnosis of Urinary Tract Infection*
- Table 2. Quantitative Urine Culture for the Diagnosis of Urinary Tract Infection*
- Table 3. Antibiotic Agents for Parenteral Treatment of a Urinary Tract Infection
- Table 4. Antibiotic Agents for the Oral Treatment of Urinary Tract Infection
- Table 5. Antibiotic Agents to Prevent Reinfection
| Method | Findings |
| Bright-field or phase-contrast microscopy of centrifuged urinary sediment | Bacteria |
| Gram stain of uncentrifuged or centrifuged urinary sediment | Bacteria |
| Nitrite and leukocyte esterase test | Positive = UTI likely |
| Nitrite test | Positive = UTI probable |
| Leukocyte esterase test | Positive = Nonspecific |
| *Negative microscopic findings for bacteria do not rule out a UTI, nor do negative results of dipstick testing for nitrite and leukocyte esterase. | |
| Method | Finding |
| Suprapubic aspiration | If a UTI is present, bacteria are likely to be proliferating in bladder urine, with growth of any organism except 2000-3000 CFU/mL coagulase-negative staphylococci. |
| Catheterization in a girl or midstream, clean-void collection in a circumcised boy | Febrile infants and children with UTI usually have >50,000 CFU/mL of a single urinary pathogen; however, UTI may be present with 10,000-50,000 CFU/mL of a single organism.* |
| Midstream, clean-void collection in a girl or uncircumcised boy | UTI is indicated when >100,000 CFU/mL of a single urinary pathogen is present in a symptomatic patient. Pyuria usually present. A UTI may be present with 10,000-50,000 CFU/mL of a single bacterium.* |
| Any method in a girl or boy | If the patient is asymptomatic, bacterial growth is usually >100,000 CFU/mL of the same organism on different days. If pyuria is absent, this result probably indicates colonization rather than infection. |
| *Patients with urinary frequency (ie, decreased bladder incubation time) are those most likely to have bacteria proliferating in the urinary bladder in the presence of low colony counts. | |
| Drug | Dosage and Route | Comment |
| Ceftriaxone | 50-75 mg/kg/day IV/IM as a single dose or divided q12h | Do not use in infants < 6wk of age; parenteral antibiotic with long half-life; may displace bilirubin from albumin |
| Cefotaxime | 150 mg/kg/day IV/IM divided q6-8h | Safe to use in infants < 6wk of age; used with ampicillin in infants aged 2-8wk |
| Ampicillin | 100 mg/kg/day IV/IM divided q8h | Used with gentamicin in neonates < 2wk of age; for enterococci and patients allergic to cephalosporins |
| Gentamicin | Term neonates < 7 days: 3.5-5 mg/kg/dose IV q24h Infants and children < 5y: 2.5 mg/kg/dose IV q8h or single daily dosing with normal renal function of 5-7.5 mg/kg/dose IV q24h Children =5y: 2-2.5 mg/kg/dose IV q8h or single daily dosing with normal renal function of 5-7.5 mg/kg/dose IV q24h | Monitor blood levels and kidney function if therapy extends >48 h |
| Note: IM = intramuscular; IV = intravenous; q = every. | ||
| Antibacterial Agent | Daily Dosage |
| Sulfisoxazole | 120-150 mg/kg divided q4-6h |
| Sulfamethoxazole and trimethoprim | 6-12 mg/kg TMP, 30-60 mg/kg SMZ divided q12h |
| Amoxicillin and clavulanic acid | 20-40 mg/kg divided q8h |
| Cephalexin | 20-50 mg/kg divided q6h |
| Cefixime | 8 mg/kg divided q12-24h |
| Cefpodoxime | 10 mg/kg divided q12h |
| Nitrofurantoin* | 5-7 mg/kg divided q6h |
| *Nitrofurantoin may be used to treat lower UTIs. However, because of its limited tissue penetration, nitrofurantoin is not suitable for the treatment of kidney infection. | |
| Agent | Single Daily Dose |
| Nitrofurantoin* | 1-2 mg/kg PO |
| Sulfamethoxazole and trimethoprim* | 1-2 mg/kg TMP, 5-10 mg/kg SMZ PO |
| Trimethoprim | 1-2 mg/kg PO |
| *Do not use nitrofurantoin or sulfa drugs in infants younger than 6 weeks. Reduced doses of an oral, first-generation cephalosporin, such as cephalexin at 10 mg/kg, may be used until the child reaches age 6 weeks. Ampicillin or amoxicillin are not recommended, because of the high incidence of resistant E coli. | |
Print
