Urinary Tract Infection — Antibiotic Recommendations — Clinical Pathway: All Settings

Urinary Tract Infection (UTI) Clinical Pathway — All Settings

Antibiotic Recommendations

  • Empiric antibiotic choices for both outpatients and inpatients:
    • Based on clinical symptoms, risk and UA results
    • Cover the most common organisms, are based on local susceptibilities
    • May not be appropriate for all pathogens
      • e.g., cefazolin/cephalexin does not cover Pseudomonas or Enterococcus species
  • Tailor antibiotic therapy based on culture and susceptibility results
    • Note: Nitrofurantoin is not appropriate treatment for pyelonephritis
    • It does not achieve therapeutic levels in the kidney
  • Durations below apply to most children
  • Longer durations are appropriate for UTIs complicated by renal abscess
    • Use ED UTI Order Set
  • CHOP Formulary

Asymptomatic Bacteriuria

Defined as presence of a positive urine culture, regardless of urinalysis results,
without signs or symptoms of a UTI.

Patient Population First-Line Empiric Therapy Allergy to First-Line Agent
Assess Need for Alternative		 Duration of Treatment/Comments
All No treatment is recommended N/A For children with indwelling catheter, consider discontinuing or changing catheter

Cystitis

Defined by the presence of all the following:

  • Dysuria, urgency, frequency, or suprapubic pain
  • No fever or other systemic symptoms
  • UA and culture consistent with UTI
Patient Population First-Line Empiric Therapy Allergy to First-Line Agent
Assess Need for Alternative		 Duration of Treatment/Comments
  • Previously healthy children without:
    • Underlying GU abnormalities
    • Catheter dependence
    • History of Pseudomonas
    • History of MDRO UTI
      • e.g., ESBL, CRE, or RGN under MDRO tab OR culture positive for one of these organisms in the past 1 year
  • Cephalexin, oral
  • 50 mg/kg/day divided every 8 hours; maximum: 500 mg/dose
  • Nitrofurantoin, oral
  • 6 mg/kg/day divided every 6 hours; maximum: 100 mg/dose
  • 5 days, other than exceptions below
  • 3 days for co-trimoxazole or ciprofloxacin if these are selected after susceptibilities are available
  • Special populations:
    • Complex GU anatomy
    • Catheter dependent
    • Neurogenic bladder
  • Review recent culture results and susceptibilities from last 3 cultures if available and target empiric antibiotics based on culture results
  • If no prior results:
    • Nitrofurantoin, oral
    • 6 mg/kg/day divided every 6 hours; maximum: 100 mg/dose
 7 days
  • History of:
    • Pseudomonas UTI
    • Other UTI caused by MDRO
      • e.g., ESBL, CRE, or RGN under MDRO tab OR culture positive for one of these organisms in the past 1 year
  • Review recent culture results and susceptibilities, e.g., last 3 cultures if available and target empiric antibiotics based on culture results
  • If no prior results:
    • Ciprofloxacin, oral
    • 10 mg/kg/dose every 12 hours; maximum: 750 mg/dose
  • Discuss with ID as needed
  • 3 days for co-trimoxazole or ciprofloxacin
  • 5 days for all other antibiotics
  • 7 days if GU abnormality or catheter dependent

Pyelonephritis

Defined by presence of the following:

  • Fever or flank pain
  • UA and culture consistent with UTI
Patient Population First-Line Empiric Therapy Allergy to First-Line Agent
Assess Need for Alternative		 Duration of Treatment/Comments
  • Previously healthy children without:
    • Underlying GU abnormalities
    • Catheter dependence
    • History of Pseudomonas
    • History of MDRO UTI
      • e.g., ESBL, CRE, or RGN under MDRO tab OR culture positive for one of these organisms in the past 1 year
  • Cefazolin, IV
  • 20 mg/kg/dose every 8 hours; maximum: 1,000 mg/dose
  • Or
  • If tolerating oral:
    • Cephalexin, oral
    • 50 mg/kg/day divided every 8 hours; maximum: 500 mg/dose
  • Aztreonam, IV
  • 30 mg/kg/dose every 8 hours; maximum: 1,000 mg/dose
  • Or
  • If tolerating oral:
    • Ciprofloxacin, oral
    • 10 mg/kg/dose every 12 hours; maximum: 750 mg/dose
 7 days
  • Child requiring hospitalization with:
    • History of prior UTI or ill-appearing
  • Review prior culture results and susceptibilities; e.g., last 3 cultures, to determine empiric treatment
  • If no prior results:
    • Ceftriaxone, IV
    • 50 mg/kg/dose every 24 hours; maximum: 2,000 mg/dose
  • Aztreonam, IV
  • 30 mg/kg/dose every 8 hours; maximum: 1,000 mg/dose
 7 days
  • Special populations:
    • Complex GU anatomy
    • Catheter-dependent
    • Neurogenic bladder
    • History of Pseudomonas or other MDRO
      • e.g., ESBL, CRE, or RGN under MDRO tab OR culture positive for one of these organisms in the past 1 year
  • Review recent culture results and susceptibilities; e.g., last 3 cultures if available to determine empiric treatment
  • If no prior results:
    • Cefepime, IV
    • < 50 kg: 50 mg/kg/dose every 8 hours; maximum: 2,000 mg/dose
    • ≥ 50 kg and/or ≥ 18 years: 2,000 mg every 8 hours
  • Or
  • If tolerating oral:
    • Ciprofloxacin, oral
    • 10 mg/kg/dose every 12 hours; maximum: 750 mg/dose
  • Aztreonam, IV
  • 30 mg/kg/dose every 8 hours; maximum: 1,000 mg/dose
  • Or
  • If tolerating oral:
    • Ciprofloxacin, oral
    • 10 mg/kg/dose every 12 hours; maximum: 750 mg/dose
  • 7 days
  • Complex GU anatomy:
    • Up to 14 days max
    • May consider 7-10 days if adequate source control and prompt response to therapy