urinary%20tract%20infection%20(pediatric)
URINARY TRACT INFECTION (PEDIATRIC)
Nonspecific urinary tract infection symptoms in infants <3 months are fever, feeding difficulties, vomiting, lethargy, irritability and failure to thrive.
Toddlers and preschoolers have unusual odor of urine, abdominal or flank pain, frequency, dysuria, and urgency.
School-age children have the classical symptoms of fever, frequency, urgency and dysuria.
Consider UTI in all seriously ill children even when there is evidence of infection outside the urinary tract.

Principles of Therapy

Consider hospital admission in the following patients:

  • Who need intravenous (IV) fluids
  • Who need intravenous (IV) antibiotics because of severe illness
  • Unresponsive to oral antibiotics
  • ≤4 months of age
  • W/ questionable compliance w/ treatment
  • W/ difficulty w/ follow-up
  • W/ whom clinician or family is uncomfortable managing the patient as an outpatient

Outpatient Pharmacotherapy

  • Starting empiric treatment w/ a broad-spectrum antibiotic is recommended in a patient w/ presumptive urinary tract infection (UTI) once a specimen for culture & urinalysis, preferably obtained from catheterization or suprapubic bladder aspiration (SPA), is sent
  • The agent to be given should be based on the antibiotic susceptibility patterns of the infecting pathogen
  • Timely treatment w/ 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 w/ acute pyelonephritis but do not require hospital admission

Cephalosporins

  • 1st-, 2nd- & 3rd-generation cephalosporins may be used in the treatment of urinary tract infection (UTI)
  • Oral Cefixime has been shown to be cost-effective & efficacious

Penicillins

  • Eg Amoxicillin, Ampicillin, Co-amoxiclav

Quinolones

  • Eg Ciprofloxacin, Nalidixic acid
  • Provides excellent coverage against Gram-positive & 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 (UTI)

Others

  • Co-trimoxazole
  • Nitrofurantoin
    • Not considered adequate for pyelonephritis because of poor tissue penetration
    • 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

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 w/ upper urinary tract infection (UTI)/acute pyelonephritis

Inpatient Pharmacotherapy

  • An immunocompromised patient or infant younger than 2 mth is assumed to have acute pyelonephritis or complicated urinary tract infection (UTI) & should be managed in the hospital

Parenteral Antibiotic Therapy

  • Ampicillin or cephalosporin plus aminoglycoside (eg Gentamicin, Tobramycin) cover most urinary tract pathogens
    • Once-daily dosing is recommended for patients receiving aminoglycosides
    • Ampicillin provides coverage against Gram-positive cocci or Enterococcus
  • 3rd- or 4th-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)
    • Eg Ceftazidime, Cefotaxime, 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 patient is clinically stable & afebrile for 48-72 hours
  • A short course of intravenous (IV) antibiotics followed by oral antibiotics is as effective as a longer duration of intravenous (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 w/ upper urinary tract infection (UTI)/acute pyelonephritis
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