Urinary tract infections in children

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

vesicoureteral reflux: no history of febrile UTIs

1st line – consider prophylactic antibiotics

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1st line –

consider prophylactic antibiotics

The American Urological Association recommends antibiotic prophylaxis for children ages <1 year with grade 3 to 5 vesicoureteral reflux (VUR) identified through screening, without a history of febrile UTI. Antibiotic prophylaxis may be considered for children with grade 1 to 2 VUR identified through screening without a history of febrile UTI.[37]

Suitable choices for prophylaxis include a first- or second-generation cephalosporin, trimethoprim, trimethoprim/sulfamethoxazole, or nitrofurantoin.[1][85] Nitrofurantoin and trimethoprim are preferred where available.[1]

Trimethoprim/sulfamethoxazole is active against multiple antibiotic-resistant bacteria, including extended-spectrum beta-lactamase (ESBL)-producing Enterobacterales such as Escherichia coli and AmpC-beta-lactamase-producing Enterobacterales such as Klebsiella species.[71] Nitrofurantoin is active against cystitis caused by ESBL-producing Enterobacterales and AmpC-beta-lactamase-producing Enterobacterales.[71]

Where possible, choice of prophylactic antibiotic should be guided by recent culture and sensitivity results. Rotating the prophylactic antibiotic used may increase the risk of antibiotic resistance. If a child develops acute UTI while taking prophylaxis, a different antibiotic should be used to treat the acute infection.[85]

The risk of resistance increases with the duration of antibiotic therapy. A course of prophylactic antibiotics usually lasts 3 to 6 months, after which it should be reassessed.[37][38]

Primary options

nitrofurantoin: 1 mg/kg orally once daily at bedtime

trimethoprim: 2 mg/kg orally once daily at bedtime

Secondary options

cephalexin: 10-15 mg/kg orally once daily at bedtime

sulfamethoxazole/trimethoprim: children ≥2 months of age: 1-2 mg/kg orally once daily at bedtime

ACUTE

age ≤2 months

1st line – parenteral or oral antibiotics

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1st line –

parenteral or oral antibiotics

Neonates and infants ages ≤2 months are at high risk for serious bacterial infection and sepsis.[1][40] Symptoms are nonspecific in this age group, making it difficult to distinguish UTI from other causes of serious bacterial infection at initial evaluation.[41][58] These patients should be admitted to hospital for evaluation and most should receive empiric parenteral antibiotic therapy. See Sepsis in children for more information.

Oral antibiotics may be appropriate for well-appearing, febrile, term infants ages 29 to 60 days who have positive urinalysis result and normal inflammatory markers.[58]

Choice of empiric therapy is guided by past infections and associated antibiotic susceptibility data from the past 6 months, antibiotic exposures within the past 30 days, and local antimicrobial resistance patterns.[71] Suitable regimens include ampicillin plus gentamicin, or ampicillin plus a third-generation cephalosporin (e.g., cefotaxime, cefepime, ceftriaxone).[67][73] The UK National Institute for Health and Care Excellence (NICE) recommends a third-generation cephalosporin plus an antibiotic active against listeria (e.g., ampicillin) for infants ages <3 months admitted to hospital with fever.[74]

Gentamicin is active against multiple antibiotic-resistant bacteria, including extended-spectrum beta-lactamase-producing Enterobacterales such as Escherichia coli, AmpC-beta-lactamase-producing Enterobacterales such as Klebsiella species, and Pseudomonas aeruginosa with difficult-to-treat resistance.[71] Cefepime is active against AmpC-beta-lactamase-producing Enterobacterales.[71]

Adjust therapy to the nearest spectrum antibiotic treatment following complete identification of the pathogen and determination of susceptibility data.

Consult a specialist for guidance on antibiotic selection in patients with penicillin allergy and those who are immunosuppressed, have renal impairment, or do not respond adequately to initial treatment. Treatment for penicillin-allergic patients depends on the age of the patient, history of drug allergy, and severity of illness. However, allergy to penicillin is generally not a concern in neonates and young infants because they have not been challenged with penicillin before.

Lack of response to initial therapy may indicate that the organism is not susceptible to the antimicrobial agent used, or indicate the development of pyonephrosis, renal abscess, or obstructed urine drainage. Culture results should be reviewed and urgent ultrasound performed.

Treatment is usually given for 7 to 14 days.[40]

Primary options

ampicillin: neonates: consult specialist for guidance on dose; infants: 50-200 mg/kg/day intravenously given in divided doses every 6 hours, maximum 8 g/day

-- AND --

gentamicin: neonates: consult specialist for guidance on dose; infants: 5 to 7.5 mg/kg intravenously every 24 hours

cefotaxime: neonates: consult specialist for guidance on dose; infants: 150-180 mg/kg/day intravenously given in divided doses every 8 hours, maximum 8 g/day

ceftriaxone: neonates: consult specialist for guidance on dose; infants: 50-75 mg/kg/day intravenously given in divided doses every 12-24 hours

cefepime: neonates: consult specialist for guidance on dose; infants: 100 mg/kg/day intravenously given in divided doses every 12 hours, maximum 4 g/day

amoxicillin/clavulanate: neonates: consult specialist for guidance on dose; infants: 30 mg/kg/day orally given in 2 divided doses

Consider – supportive care

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Consider –

supportive care

Treatment recommended for SOME patients in selected patient group

Some patients may require supportive care with intravenous fluids and/or an antipyretic (e.g., acetaminophen).

Primary options

acetaminophen: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day

Consider – antifungal therapy

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Consider –

antifungal therapy

Treatment recommended for SOME patients in selected patient group

May be required in immunosuppressed patients. Consult local guidelines for choice of antifungal regimen.

age >2 months

uncomplicated UTI

1st line – oral antibiotics

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1st line –

oral antibiotics

An uncomplicated UTI is one that occurs in a child who has a structurally and functionally normal urinary tract, normal renal function, and a competent immune system. Uncomplicated UTIs generally involve the lower urinary tract (cystitis) rather than the upper urinary tract.[1]

Children with uncomplicated UTI may have mild pyrexia and mild dehydration, but do not have vomiting or any signs of sepsis, dehydration, or hemodynamic instability.

The decision to start empiric antibiotic therapy is informed by the child’s likelihood of having a UTI and their overall clinical condition. Children who have a positive urinalysis but are not systemically unwell may be monitored closely until urine culture results are available.[1][4]

Treat febrile UTIs as soon as possible (within 48-72 hours) to avoid subsequent renal scarring.[1][26]

Choice of empiric therapy is guided by local antimicrobial resistance patterns. Therapy should be reviewed when the organism and its antimicrobial sensitivities are confirmed by culture, and changed to a narrower-spectrum agent if appropriate. Cure rates with antibiotics exceed 95%.[69]

Oral therapy is usually appropriate for children with uncomplicated lower UTI. Options include a second- or third-generation cephalosporin (e.g., cefixime), amoxicillin/clavulanate, trimethoprim, trimethoprim/sulfamethoxazole, or nitrofurantoin.[1][70][71] Cephalexin or amoxicillin may be used second-line if culture results confirm susceptibility.[88]

Treatment for penicillin-allergic patients depends on the age of the patient, history of drug allergy, and severity of illness. Consult a specialist for guidance on antibiotic selection in these patients. Allergy to penicillin is generally not a concern in neonates and young infants because they have not been challenged with penicillin before.

Typical treatment course is 7-14 days.[1] One systematic review found that a 2- to 4-day course of antibiotics was as effective as a 7- to 14-day course at eradicating lower urinary tract infection in children.[72] A 3- to 5-day course may be considered.[1]

Primary options

cefixime: 8 mg/kg/day orally given in 1-2 divided doses

amoxicillin/clavulanate: 20-40 mg/kg/day orally given in 3 divided doses; 25-45 mg/kg/day orally given in 2 divided doses

trimethoprim: 4-6 mg/kg/day orally given in 2 divided doses

sulfamethoxazole/trimethoprim: 6-12 mg/kg/day orally given in 2 divided doses

nitrofurantoin: 5-7 mg/kg/day orally given in 4 divided doses

Secondary options

cephalexin: 25-50 mg/kg/day orally given in 2-4 divided doses, maximum 500 mg/dose

amoxicillin: 20-40 mg/kg/day orally given in 3 divided doses; 25-45 mg/kg/day orally given in 2 divided doses

complicated UTI: no structural renal disease

1st line – oral or intravenous antibiotics

Back

1st line –

oral or intravenous antibiotics

A complicated UTI is one that occurs in a child who has a structural or functional abnormality of the urinary tract. Complicated UTIs generally involve the upper urinary tract (pyelonephritis) rather than the lower urinary tract.[1]

The choice between oral and intravenous therapy depends on patient age, suspicion of sepsis, illness severity, hydration status, tolerance for oral medication, and whether there are complications of infection.[1] The National Institute for Health and Care Excellence in the UK recommends intravenous antibiotics for children with pyelonephritis who are vomiting, unable to take oral antibiotics, or severely unwell.[75]

Choice of empiric therapy is guided by past infections and associated antibiotic susceptibility data from the past 6 months, antibiotic exposures within the past 30 days, and local antimicrobial resistance patterns.[71] Therapy should be reviewed when the organism and its antimicrobial sensitivities are confirmed by culture, and changed to a narrower-spectrum agent if appropriate.

Examples of suitable oral antibiotics include cephalexin, cefixime, and amoxicillin/clavulanate (if cultures confirm sensitivity).[1][75] Cefuroxime, ceftriaxone, gentamicin (with or without ampicillin), amikacin, or tobramycin may be used if intravenous treatment is required.[1][75]

Ampicillin is added to cover Enterococci.[67] Amikacin is active against extended-spectrum beta-lactamase (ESBL)-producing Enterobacterales such as Escherichia coli.[71] Tobramycin is active against multiple antibiotic-resistant bacteria, including ESBL-producing Enterobacterales, AmpC-beta-lactamase-producing Enterobacterales such as Klebsiella species, and Pseudomonas aeruginosa with difficult-to-treat resistance.[71]

Treatment course is 7-14 days.[89] Switching from parenteral to oral antibiotic treatment in a stepwise manner for hospitalized patients should be considered whenever possible.[71] One systematic review reported no significant difference in microbiologic eradication, renal scarring, clinical cure, reinfection, persistence of acute pyelonephritis, or reinfection in children who were switched to oral antibiotics after 5-10 days, compared with children who received intravenous antibiotics for 14 days.[76]

Nitrofurantoin should be avoided in children with renal impairment. Lack of response to initial therapy may indicate that the organism is not susceptible to the antimicrobial agent used, or indicate the development of pyonephrosis, renal abscess, or obstructed urine drainage. Culture results should be reviewed and urgent ultrasound performed.

Primary options

cephalexin: 50-100 mg/kg/day orally given in 3-4 divided doses, maximum 1000 mg/dose

cefixime: 8 mg/kg/day orally given in 1-2 divided doses

amoxicillin/clavulanate: 20-40 mg/kg/day orally given in 3 divided doses; 25-45 mg/kg/day orally given in 2 divided doses

cefuroxime sodium: 50-100 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 9 g/day

ceftriaxone: 50-75 mg/kg/day intravenously given in divided doses every 12-24 hours

gentamicin: 5 to 7.5 mg/kg intravenously every 24 hours

ampicillin: 50-200 mg/kg/day intravenously given in divided doses every 6 hours, maximum 8 g/day

and

gentamicin: 5 to 7.5 mg/kg intravenously every 24 hours

amikacin: 15 to 22.5 mg/kg intravenously every 24 hours

tobramycin: 2 to 2.5 mg/kg intravenously every 8 hours

Consider – supportive care

Back

Consider –

supportive care

Treatment recommended for SOME patients in selected patient group

Some patients may require supportive care with intravenous fluids and/or an antipyretic (e.g., acetaminophen).

Primary options

acetaminophen: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day

Consider – antifungal therapy

Back

Consider –

antifungal therapy

Treatment recommended for SOME patients in selected patient group

May be required in immunosuppressed patients. Consult local guidelines for choice of antifungal regimen.

complicated UTI: structural renal disease

1st line – oral or intravenous antibiotics

Back

1st line –

oral or intravenous antibiotics

Cephalexin or amoxicillin/clavulanate may be used as first-line oral antibiotics (if culture results are available and bacteria are susceptible).[75]

In patients with an underlying renal disorder who require broader gram-negative and Pseudomonas coverage and who are systemically stable at presentation, consider a fluoroquinolone such as oral ciprofloxacin.[77][78]

Ciprofloxacin is active against extended-spectrum beta-lactamase (ESBL)-producing Enterobacterales such as Escherichia coli and AmpC-beta-lactamase-producing Enterobacterales such as Klebsiella species.[71]

Systemic fluoroquinolone antibiotics, such as ciprofloxacin, may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[79] Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug formulary for more information on suitability, contraindications, and precautions.

Consider second-line parenteral ampicillin plus gentamicin for patients with preexisting structural renal disease and normal renal function. Alternative options include cefotaxime and ceftriaxone.[1] Both oral and intravenous formulations of cephalosporins have been demonstrated to be effective.[80]

Gentamicin is active against multiple antibiotic-resistant bacteria, including ESBL-producing Enterobacterales, AmpC-beta-lactamase-producing Enterobacterales, and Pseudomonas aeruginosa with difficult-to-treat resistance.[71]

Consult a specialist for guidance on antibiotic selection in patients with penicillin allergy and those who are immunosuppressed, have renal impairment, or fail to respond adequately to initial treatment. Treatment for penicillin-allergic patients depends on the age of the patient, history of drug allergy, and severity of illness.

Primary options

cephalexin: 50-100 mg/kg/day orally given in 3-4 divided doses, maximum 1000 mg/dose

amoxicillin/clavulanate: 20-40 mg/kg/day orally given in 3 divided doses; 25-45 mg/kg/day orally given in 2 divided doses

ciprofloxacin: 20-40 mg/kg/day orally given in 2 divided doses

Secondary options

ampicillin: 50-200 mg/kg/day intravenously given in divided doses every 6 hours, maximum 8 g/day

and

gentamicin: 5 to 7.5 mg/kg intravenously every 24 hours

cefotaxime: 150-180 mg/kg/day intravenously given in divided doses every 8 hours, maximum 8 g/day

ceftriaxone: 50-75 mg/kg/day intravenously given in divided doses every 12-24 hours

Consider – supportive care

Back

Consider –

supportive care

Treatment recommended for SOME patients in selected patient group

Some patients may require supportive care with intravenous fluids and/or an antipyretic (e.g., acetaminophen).

Primary options

acetaminophen: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day

Consider – antifungal therapy

Back

Consider –

antifungal therapy

Treatment recommended for SOME patients in selected patient group

May be required in immunosuppressed patients. Consult local guidelines for choice of antifungal regimen.

ONGOING

recurrent UTIs

1st line – consider prophylactic antibiotics

Back

1st line –

consider prophylactic antibiotics

A recurrent UTI is defined by the UK National Institute for Health and Care Excellence as: ≥2 episodes of acute pyelonephritis, or 1 episode of acute pyelonephritis plus at least one episode of cystitis, or ≥3 episodes of cystitis.[4]

Recurrent UTIs may be due to unresolved infection (initial treatment is inadequate for elimination of bacteria in the urinary tract) or persistent infection (caused by re-emergence of bacteria in the urinary tract due to a site of persistent infection that cannot be eradicated [e.g., infected stones or fistulas]). The same pathogen is implicated in each recurrent infection.[1]

The American Urological Association recommends antibiotic prophylaxis for children ages <1 year with vesicoureteral reflux (VUR) and a history of febrile UTI. The use of antibiotic prophylaxis for children ages ≥1 year with VUR is determined on a case-by-case basis. Clinical context, including the presence of bladder bowel dysfunction (BBD), patient age, VUR grade, the presence of scarring, and parental preferences, should be taken into account. Prophylaxis is recommended for children with both VUR and BBD.[37]

A course of prophylactic antibiotics may be considered for toilet-trained children with BBD and recurrent UTIs, while optimizing bladder and bowel management.[19]

Prophylaxis may also be considered in children with a major urologic anomaly.[38]

Prophylactic antibiotics have not been conclusively shown to reduce the risk of recurrent infection or renal scarring in children with or without VUR.[81][82][83][84] [ ]

Suitable choices for prophylaxis include a first- or second-generation cephalosporin (e.g., cephalexin), trimethoprim, sulfamethoxazole, trimethoprim/sulfamethoxazole, or nitrofurantoin.[1][85] Nitrofurantoin and trimethoprim are preferred where available.[1]

Where possible, choice of prophylactic antibiotic should be guided by recent culture and sensitivity results. Rotating the prophylactic antibiotic used may increase the risk of antibiotic resistance. One meta-analysis calculated that one multidrug-resistant infection occurs for every 21 patients with VUR treated with antibiotic prophylaxis.[86] If a child develops acute UTI while taking prophylaxis, a different antibiotic should be used to treat the acute infection.[85]

The risk of resistance increases with the duration of antibiotic therapy. A course of prophylactic antibiotics usually lasts 3 to 6 months, after which it should be reassessed.[37][38]

Primary options

nitrofurantoin: 1 mg/kg orally once daily at bedtime

trimethoprim: 2 mg/kg orally once daily at bedtime

Secondary options

cephalexin: 10-15 mg/kg orally once daily at bedtime

sulfamethoxazole/trimethoprim: children ≥2 months of age: 1-2 mg/kg orally once daily at bedtime

Consider – optimize bladder and bowel function

Back

Consider –

optimize bladder and bowel function

Treatment recommended for SOME patients in selected patient group

Any bladder or bowel dysfunction associated with recurrent UTIs must be addressed. Bladder bowel dysfunction increases the risk of recurrent UTI twofold, and increases the risk of breakthrough UTI in children who also have vesicoureteral reflux.[25][27] Children and caregivers should be educated about adequate hydration and ready access to toilets, to prevent delayed voiding.[4] Constipation should be treated to prevent further infections. Fecal disimpaction with laxatives and enemas is followed by maintenance therapy with stool softeners such as polyethylene glycol.[19] Maintenance therapy may be required for months or years.

Consider – urology referral

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Consider –

urology referral

Treatment recommended for SOME patients in selected patient group

Surgical management of high-grade vesicoureteral reflux (VUR) has also generally been recommended for children with recurrent UTI, but the added benefit of surgical or endoscopic correction of VUR over antibiotic treatment alone is unclear.[84][87] [ ] Refer patients with grade IV/V VUR or a significant urologic anomaly to a urologist.[38]

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Urinary tract infections in children

Treatment algorithm

vesicoureteral reflux: no history of febrile UTIs

consider prophylactic antibiotics

Primary options

Secondary options

age ≤2 months

parenteral or oral antibiotics

Primary options

supportive care

Primary options

antifungal therapy

age >2 months

oral antibiotics

Primary options

Secondary options

oral or intravenous antibiotics

Primary options

supportive care

Primary options

antifungal therapy

oral or intravenous antibiotics

Primary options

Secondary options

supportive care

Primary options

antifungal therapy

recurrent UTIs

consider prophylactic antibiotics

Primary options

Secondary options

optimize bladder and bowel function

urology referral