Urinary%20tract%20infection%20(pediatric) Treatment

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

• 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 UTI/acute pyelonephritis

• A 7-14 day course of antibiotics should be given to patients w/ upper UTI/acute pyelonephritis

• 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