pediatrics
Urinary Tract Infection (UTI) in Children
Treatment of UTI in Children
Antibiotics For severe VUR, sometimes antibiotic prophylaxis and surgical repair Treatment of urinary tract infection is aimed at eliminating the acute infection, preventing urosepsis, and preserving renal parenchymal function. Antibiotics are begun presumptively in all toxic-appearing children and in nontoxic children with a probable UTI (positive leukocyte esterase, nitrites, or pyuria). Others can await the results of the urine culture, which are important for both confirming the diagnosis of UTI and yielding antimicrobial susceptibility results ( Treatment references ). In infants and children > 2 months of age with toxicity, dehydration, or inability to retain oral intake, parenteral antibiotics are used, typically a 3rd-generation cephalosporin (eg,ceftriaxone75 mg/kg IV/IM every 24 hours,cefotaxime50 mg/kg IV every 6 or 8 hours). A 1st-generation cephalosporin (eg,cefazolin) may be used if typical local pathogens are known to be sensitive. Aminoglycosides (eg,gentamicin), although potentially nephrotoxic, may be useful in complex UTIs (eg, urinary tract abnormalities, presence of indwelling catheters, recurrent UTIs) to treat potentially resistant gram-negative bacilli such asPseudomonas. If blood cultures are negative and clinical response is good, an appropriate oral antibiotic (eg,cefixime,cephalexin,trimethoprim/sulfamethoxazole [TMP/SMX],amoxicillin/clavulanic acid, or, for selected children such as those>1 year with complicated UTI caused by multidrug-resistantE. coli,P. aeruginosa, or other gram-negative bacteria, a fluoroquinolone) selected on the basis of antimicrobial sensitivities can be used to complete a 7- to 10-day course. A poor clinical response (eg, fever persisting > 72 hours) suggests a resistant organism or an obstructive lesion and warrants urgent evaluation with ultrasonography and repeat urine culture. In nontoxic, nondehydrated infants and children who are able to retain oral intake, oral antibiotics may be given initially. The drug of choice is TMP/SMX 5 to 6 mg/kg (of TMP component) 2 times a day. Alternatives include cephalosporins such ascefixime8 mg/kg once a day,cephalexin25 mg/kg 4 times a day, oramoxicillin/clavulanic acid15 mg/kg 3 times a day. Therapy is changed based on the results of cultures and antimicrobial sensitivities. Treatment is typically for 7 to 10 days, although shorter treatment courses are being evaluated. Treatment may be given for up to 14 days if pyelonephritis is thought to be present and clinical response is slow. Routine repeated urinalysis or urine culture is not necessary unless efficacy is not clinically apparent. It has long been thought that antibiotic prophylaxis reduces UTI recurrences and prevents kidney damage and should be started after a first or second febrile UTI in children with VUR. However, this conclusion was not based on long-term, placebo-controlled trials (important because it has been observed that much VUR abates with time as children mature). A large, controlled trial, the Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) trial ( Treatment references ), did show that antibiotic prophylaxis using TMP/SMX reduced UTI recurrences by 50% (from about 25% to 13%) compared to placebo but did not show a difference in the rate of renal scarring at 2 years (8% in each group). Also, the children in the trial who did develop UTI while taking prophylactic antibiotics were 3 times as likely to be infected with resistant organisms. However, because the 2-year follow-up period is likely too short to draw firm conclusions regarding prevention of renal scarring, additional study may show that antibiotic prophylaxis does provide some renal protection but at the risk of more antibiotic-resistant infections. Thus, the optimal strategy remains somewhat uncertain. Nonetheless, for children with grade IV or V VUR, open repair or endoscopic injection of polymeric bulking agents is usually recommended, often along with antibiotic prophylaxis until repair is completed. For children with lesser grades of VUR, further research is required. Because renal complications are probably unlikely after only one or two UTIs, pending further research one acceptable strategy may be to closely monitor children for UTIs, treat them as they occur, and then reconsider antimicrobial prophylaxis in those children with recurrent infections (especially for those with recurrent febrile UTIs, more severe VUR, or bowel or bladder dysfunction). 2 mg/kg orally once a day or TMP/SMX 3 mg/kg orally (of TMP component) once a day ( Treatment references ), usually given at bedtime. 1.Mattoo YK, Shaikh N, Nelson CP: Contemporary management of urinary tract infection in children.Pediatrics147:e2020012138, 2021. doi: 10.1542/peds.2020-012138 2.The RIVUR Trial Investigators: Antimicrobial prophylaxis for children with vesicoureteral reflux.NEJM370:2367–2376, 2014. doi: 10.1056/NEJMoa1401811 3.Nelson CP, Hoberman A, Shaikh N, et al: Antimicrobial resistance and urinary tract infection recurrence.Pediatrics137(4):e20152490, 2016. doi: 10.1542/peds.2015-2490 