Pediatric Urinary Tract Infection Treatment & Management

Prehospital care is rarely applicable in patients with urinary tract infection (UTI), although patients who are uroseptic and in shock may present via emergency medical service (EMS), in which case, standard supportive measures for septic patients should be followed. Patients with a nontoxic appearance may be treated with oral fluids and antibiotics.

Toxic-appearing patients must be aggressively treated with intravenous fluids and parenteral antibiotics.

Most cases of uncomplicated UTI respond readily to outpatient antibiotic treatments without further sequelae.

Appropriate treatment, imaging, and follow-up prevent long-term sequelae in patients with more severe cases or chronic infections. All patients should have close follow-up to evaluate response to antibiotics. Repeat urinalysis and/or urine cultures are not needed if the patient's condition responds to therapy as expected.

The American Academy of Pediatrics recommends that all infants and young children (aged 2 mo to 2 y) with a first UTI undergo urinary tract ultrasonography and VCUG. These tests should be acquired promptly if patients fail to show expected clinical response within 2 days of treatment.

Low-grade VUR usually resolves without permanent damage, but high-grade VUR may require surgical correction.

Antibiotic resistance among uropathogens is increasing dramatically. Be aware that previous antibiotic exposure (ie, for otitis media) has been found to be associated with drug-resistant UTIs and should be kept in mind when choosing empiric therapy.^[21]

Go to Urinary Tract Infection in Males and Urinary Tract Infection in Females for complete information on these topics.

Infants younger than 8 weeks with a febrile UTI

The diagnosis in infants younger than age 8 weeks with a febrile UTI is usually based on fever and on positive results from a urine specimen obtained by catheterization. Infants with such findings are usually hospitalized and receive parenteral antibiotic therapy (see Table 3, below). However, clinical judgment may indicate that home treatment is appropriate. Parenteral antibiotics may be used with daily follow-up until the patient is afebrile for 24 hours. Complete 10-14 days of therapy with an oral antibiotic that is active against the infecting bacteria.

A retrospective review of more than 1500 babies aged 29-60 days with fever and culture-proven UTIs were analyzed for high-risk criteria on presentation. Those infants without a high-risk past medical history and not clinically ill on presentation to an ED, along with low-risk laboratory values, were at low risk overall for bacteremia and serious adverse events, such as meningitis, or need for ICU support. Consideration for briefer hospitalization and close outpatient management can be made for this subgroup of young infants aged 29-60 days with UTIs. If the medical history is concerning, then these infants should be treated as younger infants aged 0-28 days.^[22]

A secondary analysis of a multicenter retrospective review found that sterile cerebrospinal fluid pleocytosis occurred in 214 (18%) of 1190 febrile young infants (aged 29-60 d) studied with culture-proven UTIs. These patients are at very low risk for adverse events and may be considered for shorter courses of intravenous antibiotics.^[23]

Table 3. Antibiotic Agents for Parenteral Treatment of a Urinary Tract Infection (Open Table in a new window)

Infants and children aged 2 months to 2 years with a first febrile UTI

The American Academy of Pediatrics issued Clinical Practice Guidelines regarding the diagnosis and management of initial UTI in febrile infants and children aged 2-24 months, summarized as follows^[5] :

• After 7-14 days of antimicrobial treatment, close clinical follow-up monitoring should be maintained to permit prompt diagnosis and treatment of recurrent infections.
• Ultrasonography of the kidneys and bladder should be performed to detect anatomic abnormalities.
• Because data do not support the use of antimicrobial prophylaxis to prevent febrile recurrent UTI in infants with no vesicoureteral reflux (VUR) or with grade I to IV VUR, a voiding cystourethrography (VCUG) is not recommended routinely after the first UTI.
• VCUG is indicated if renal and bladder ultrasonography reveals hydronephrosis, scarring, or other findings that suggest either high-grade VUR or obstructive uropathy.
• VCUG should be performed if there is a recurrence of a febrile UTI, even if previous ultrasound examination was unremarkable.

If clinical findings indicate that immediate antibiotic therapy is indicated, a urine specimen for urinalysis and culture should be obtained by means of suprapubic aspiration or catheterization before treatment is started.

Some evidence suggests no significant differences in efficacy between IV antibiotic therapy given for 3 days followed by oral therapy for another 11 days and 14 days of oral therapy. These data are based on a randomized control trial of 306 children aged 1-24 months that compared oral cefixime for 14 days with IV cefotaxime for 3 days followed by oral cefixime for 11 days. No notable differences were observed in short- or long-term outcomes (eg, clinical response, reinfection, renal scars at 6 mo).

These data led to the recommendation that children with a febrile UTI should receive oral treatment with a second- or third-generation cephalosporin, amoxicillin clavulanate, or sulfamethoxazole-trimethoprim (SMZ-TMP) (see Table 4).

Table 4. Antibiotic Agents for the Oral Treatment of Urinary Tract Infection (Open Table in a new window)

A child treated with oral antibiotics should not be acutely ill or toxic, and he or she should not have persistent vomiting or moderate to severe dehydration. Daily follow-up and good compliance is essential with this management.

The chart below details a treatment approach for febrile infants younger than 3 months with a temperature of more than 38°C.

Inpatient treatment of children with complicated pyelonephritis

Provide appropriate parenteral fluids, usually at 1-1.5 times the usual maintenance rate.

Parenteral treatment with a third-generation cephalosporin, such as ceftriaxone or cefotaxime is appropriate initial empiric coverage for a complicated UTI and pyelonephritis to cover for ampicillin-resistant, gram-negative pathogens (see Table 3). Add ampicillin if gram-positive cocci are present in the urinary sediment or if no organisms are observed. Gentamicin is an alternative for term infants older than 7 days, for older children, and for adolescents who are allergic to cephalosporins. Monitor renal function and blood aminoglycoside levels if this medication is required for more than 48 hours.

Results of urine culture and sensitivity studies are usually available within 48 hours. If the pathogen is sensitive to the antibiotic used and if the child is improving, continue treatment with the parenteral route until the child is afebrile for 24-36 hours. An oral antibiotic that is effective against the infecting organism may then be substituted for parenteral therapy (see Table 4).

The hospitalized patient is usually ready to go home after 48-72 hours. Continue therapeutic doses of antibiotics for a total of 10-14 days of antibiotic therapy. Antibacterial therapy should be given to prevent reinfection (see Table 5, below) and should continue at least until a VCUG is obtained (if one is to be obtained).

Table 5. Antibiotic Agents to Prevent Reinfection (Open Table in a new window)

Children with cystitis

Children with cystitis usually do not require special medical care other than appropriate antibiotic therapy and symptomatic treatment if voiding symptoms are marked. Antibiotic therapy is started on the basis of the practitioner's appraisal of the patient's clinical history and urinalysis results before the diagnosis is documented.

Systematic reviews of treatments for cystitis in children showed no difference in the efficacy with 7-14 days of therapy compared with 2-4 days. Single-dose or single-day therapy is not recommended in children with cystitis.

Symptomatic relief for dysuria consists of increasing fluid intake to enhance urine dilution and output, acetaminophen, and nonsteroidal anti-inflammatory drugs. If voiding symptoms are severe and persistent, add phenazopyridine hydrochloride (Pyridium). Do not administer phenazopyridine hydrochloride for longer than 48 hours, because of the risk of methemoglobinemia, hemolytic anemia, and other adverse reactions.

Sitting in a tub of warm water for 20-30 minutes 3-4 times a day often affords symptomatic relief. Patients with severe voiding discomfort may obtain relief by using an appropriately sized rectal suppository of belladonna and opium. Inform the patient to use these suppositories no more than 4 times a day and for no longer than 2 days.

A 4-day course of an oral antibiotic agent is recommended for the treatment of cystitis (see Table 4). If the clinical response is not satisfactory after 2-3 days, alter therapy on the basis of antibiotic susceptibility.

Many studies have failed to show reductions in the incidence of recurrent urinary tract infections (UTIs) with the use of antibiotic prophylaxis. Upon review, however, many did not have sufficient statistical power to detect differences or did not have stringent definitions of UTI and inclusion criteria.^{[24, 25, 26, 27, 28]}

A study that evaluated 12 months of prophylaxis with sulfamethoxazole-trimethoprim (SMZ-TMP) compared with placebo to prevent UTI showed a small, but significant, reduction in incidence but did not show any difference in renal scarring. In addition, a significant increase in UTI with SMZ-TMP-resistant organisms occurred in the treatment group.^[29]

A meta-analysis of 12 randomized controlled trials encompassing more than 1500 patients concluded that long-term antibiotics reduced the risk of more symptomatic infections; however, the benefit is small and must be weighed against the likelihood that future infections may be with bacteria that are resistant to the antibiotic administered.^[30]

In patients with pyelonephritis, some clinicians discontinue antibacterial therapy 1-2 days after VCUG if no VUR is present.

However, in studies that used cortical scanning, roughly one half of children with an initial episode of pyelonephritis had VUR, and one half had no radiographically identifiable reflux. Reinfection was common in both groups, with a high incidence in the first 6 months after the initial infection.

Until evidence-based guidelines about the use of suppressive antibacterial therapy after an initial febrile UTI are available, recommending 6-12 months of suppressive treatment seems reasonable. Patients with VUR of grade III should receive a prolonged course of suppressive therapy.

Avoid unnecessary use of antibiotics for upper respiratory infections and otitis media. Antibiotics can alter GI and periurethral flora and compromise natural defenses against colonization by pathogenic agents.

Treat voiding dysfunction, especially when it is associated with posturing, which can lead to urethrovesical reflux and recurrence of UTIs. Consider circumcision of male neonates.

One study investigated the effect of daily cranberry juice in female children with recurrent UTIs and concluded that daily consumption of concentrated cranberry juice can significantly prevent the recurrence of symptomatic UTIs.^[31]

An allergic reaction to antibiotic therapy is a risk.

Children with pyelonephritis may develop lobar inflammation of the kidney (lobar or focal nephronia) or renal abscess. Any inflammation of the renal parenchyma may lead to scar formation.

Long-term complications of pyelonephritis are hypertension, impaired renal function, ESRD, and complications of pregnancy (eg, UTI, pregnancy-related hypertension, low birth weight neonates).

Dehydration is the most common complication of UTI in the pediatric population. Intravenous fluid replacement is necessary in more severe cases.

Although children with a febrile UTI may qualify for outpatient care, they still are at risk for kidney damage. Initial use of a parenteral antibiotic may increase the likelihood of promptly ceasing the bacterial proliferation in the renal tissue. (However, a study by Hoberman et al indicated that oral therapy with a third-generation cephalosporin was as effective as traditional inpatient treatment with parenteral antibacterial therapy.)^[32]

If the patient is not allergic to a cephalosporin, initial treatment may consist of a single dose of ceftriaxone (75 mg/kg IV/IM q12-24h). If the patient is allergic to cephalosporin, initial treatment may be gentamicin (2.5 mg/kg IV/IM as a single dose). Start treatment with an oral antibacterial agent at therapeutic doses within the next 12-18 hours if the patient's response is satisfactory.

Arrange for a follow-up (which is usually performed by telephone) at 24 hours to monitor the patient's response to treatment and at 48 hours to modify treatment that the results of antibacterial sensitivity studies indicate a need to change. Arrange for a follow-up visit after 7-10 days to check the patient's clinical course.

Hospitalization is necessary for the following individuals with urinary tract (UTI):

• Patients who are toxemic or septic
• Patients with signs of urinary obstruction or significant underlying disease
• Patients unable to tolerate adequate oral fluids or medications
• Infants younger than 3 months with febrile UTI (presumed pyelonephritis)
• All infants younger than 1 month with suspected UTI, even if not febrile

Treat febrile UTI as pyelonephritis, and consider parenteral antibiotics and hospital admission for these patients.

Consultation with a urologist is not typically required at presentation unless obstruction of the urinary tract is evident. However, patients with VUR of grade IV or worse should be referred to a pediatric nephrologist or urologist.

Consultation with an infectious disease specialist may be useful if drug resistant or an unusual organism is suspected.