Pediatric Urinary Tract Infection Testing and Treatment Guideline (>2 months old)

Signs and Symptoms Risk Factors Testing

Pre-Verbal Verbal Not Toilet Trained Toilet Trained Not Toilet Trained Toilet Trained
 Fever  Dysuria  <12 months old  Female sex  Catheterization  Midstream clean catch
Increased risk of  Frequency  Female sex  Constipation  SPA  Consider “dirty” urine
UTI with:  Urgency/hesitancy  Uncircumcised  CAKUT  Clean catch using Quick-Wee method*3 for STI screening in
- Fever >2 days  Abdominal infant male  High grade VUR  Bag specimen for screening urinalysis in
adolescents
- Temp >102.2F & pain/flank pain  Constipation  Sexual activity infants >6mo (ONLY use to rule out UTI)
no source  New onset  CAKUT  Diabetes Mellitus  If positive nitrite, LE, or >0-2 WBC obtain
 Poor feeding incontinence  High grade VUR  Kidney stones urine for urinalysis and culture by catheter or
 Vomiting  Prior history of UTI: clean catch/Quick-Wee method
 Irritability Review prior
organisms and Order: “Urinalysis with Microscopic”
For 2-23mo UTI Risk
susceptibilities Obtain urine culture PRIOR to starting antibiotics
Calculator available at:
Note: urine culture is reflex in children <2yo,
https://uticalc.pitt.edu/
for older children a urine culture needs to be ordered separately
Urinalysis and Culture Interpretation Imaging Refer to urology:
Likely UTI Likely Contamination  Renal/bladder ultrasound for  Recurrent febrile UTI’s
 Leukocyte esterase OR  >10 per high-powered field - 1st febrile UTI in 2-24 mo  Abnormal imaging on RUS or
 Positive nitrite (not sensitive for children due squamous epithelial cells - Recurrent UTI in >24 mo VCUG
to frequent urination) OR  Non-uropathogen growth Complete after treatment unless  Need for DMSA scan
 ≥5 WBC/hpf (Lactobacillus, Corynebacterium, concern for acute complication/
AND viridans streptococci, coag-neg no improvement in 48-72 hours
 A positive urine culture growing a Staph)  VCUG for
uropathogen:  >2 pathogens growing - recurrent febrile UTI
- >50,000 CFUs/mL for catheterization - abnormalities seen on RUS
- >100,000 CFUs/mL for clean catch - atypical pathogen
- complex clinical course
- known renal scarring
Antibiotic Selection
Most Common Organisms: Escherichia coli (85-90% of UTIs), Klebsiella, Proteus, Enterococcus, and Enterobacter species
Ambulatory Empiric Treatment Inpatient Empiric Treatment Duration of Therapy
Cephalexin can be divided TID or QID:
Ceftriaxone 50mg/kg IV Q24H
Preferred Treatment 17mg/kg PO TID (max 4gm/day) OR Narrow or adjust
(max 2gm/day)
12.5mg/kg PO QID (max 4gm/day) antibiotic coverage as
soon as culture
Gentamicin sensitivities and
7-10 days
Sulfamethoxazole/trimethoprim
Beta-lactam allergy 2mo-<5yo: 7.5mg/kg IV Q24H susceptibilities
4-5mg/kg PO BID (trimethoprim component
(severe) 5-10yo: 6mg/kg IV Q24H available
for dosing; max 160mg trimethoprim/dose)
≥10yo: 4.5mg/kg IV Q24H
Considerations
Exclusion criteria: chronic kidney disease, known urinary tract abnormality, neurogenic bladder, immune deficiency.
*Quick-Wee method: clean perineum, stimulate suprapubic area with cold fluid soaked gauze, collect urine midstream
Antimicrobial Stewardship Program Approved 2016; Updated January 2022
1. Roberts KB. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics. 2011;128(3):595-610.
2. Shaw K, et al. Clinical Pathway for the Evaluation and Treatment of Children with Febrile UTI. Children’s Hospital of Philadelphia. August 2020. https://www.chop.edu/clinical-pathway/urinary-tract-infection-uti-febrile-clinical-
pathway. Accessed 27 December 2021.
3. Kaufman H, et al. Faster clean catch urine collection (Quick-Wee method) from infants: randomized controlled trial. BMJ. 2017; 357:j1341. Available at: https://www.bmj.com/content/357/bmj.j1341
4. Mattoo, T. K., Shaikh, N., & Nelson, C. P. Contemporary management of Urinary Tract Infection in children. Pediatrics. 2021;147(2): e2020012138