Urinary Tract Infections (UTI, Bladder Infection) in Children: Management

00:00 So, let’s say you suspect a patient does have a UTI, what antibiotic do you choose? Well, before you can answer that question, you have to ask a few more questions. First, how sick is this child? If a child is very sick, we’re going to use a broad-spectrum agent because we don’t have a lot of wiggle room. If we miss this bacteria, this child can get very sick. So, we’re not going to do that but if a child is relatively well appearing, is ambulatory, and is just complaining of a little bit of dysuria, you could take a gamble. “Oh, this one is 70% effective, call me if it’s not working, I’ll change the antibiotic.” In that way, you can use a more narrow-spectrum agent with fewer side effects and fewer downstream consequences for that child. You need to ask yourself what are the odds that this antibiotic covers the organism that’s causing the UTI? If an antibiotic almost never helps with urinary tract infections, it would obviously be a poor choice. And then we need to ask what are the odds this antibiotic causes something bad? There are some antibiotics with very negative side effect profiles and those we will tend to avoid.

01:12 Let’s go through this logically. Okay, we’ll talk about infants and we’ll talk about children. First, how sick is this child? Infants under 2 months are often admitted to the hospital for IV antibiotics.

01:25 Some infants 1-2 months of age may be discharged under certain circumstances.

01:30 This is because very young infants who have a urinary tract infection can go on to develop bacteremia or even sepsis. Infants over 2 months should receive oral antibiotics and do not require hospitalization. You should admit to a hospital patients who need IV antibiotics if they are ill appearing or not able to drink or take oral antibiotics. An example would be a patient with pyelonephritis who is over 2 months but very sick, not able to drink, not able to take oral antibiotics, that patient generally is admitted. For older children, simple cystitis is almost universally treated as an outpatient. An exception might be if it’s a resistant organism that is only treatable by IV antibiotics. Generally, we admit patients for pyelonephritis for IV antibiotics and send them home when they’re feeling a little bit better. Urosepsis is when a UTI goes horribly wrong and the patient is in septic shock. Those patients are obviously always admitted. So, let’s go through antibiotic selections that you might choose and what the likelihood is that antibiotic’s covered and what is the downside of that antibiotic? Let’s start with amoxicillin. Amoxicillin is a bad choice for UTIs because it only treats about half of E. coli which is by far and away, the number one most likely organism. It does treat Strep pneumo, so we want to limit its use for when we have a Strep pneumo infection. Amoxicillin-clavulinic acid is popular in some countries in Europe but is less commonly used in the United States again because it has a relatively low rate of coverage of E. coli. So, it doesn’t have good coverage but also it's got very broad coverage of organisms in general resulting in a high likelihood of diarrhea.

03:21 Trimethoprim/sulfamethoxazole, called either Bactrim or Septra depending on where you are in the United States, is generally a decent option for someone with very mild illness, say, a cystitis. It treats about 70% of E. coli and is pretty narrow coverage. So, this is a good first choice for a patient with cystitis. But remember, you can’t use Bactrim in children under 1 month of age for fear of kernicterus. First generation cephalosporins are very powerful in terms of affecting E. coli. They treat about 90% of E. coli. However, it’s 4 times a day dosing and you worry about noncompliance. It tastes great but it’s 4 times a day. Second generations can be used a little bit less often, they treat a little bit more of that E. coli. It is perhaps a little bit too broad spectrum. A lot of gram negatives are covered, you have more diarrhea, but this might be a good choice in a patient who is reasonably sick or a young infant. Third generation cephalosporins likewise, they are broad spectrum, they are very powerful. This is probably overkill for your cystitis, but this is probably a good choice for a very sick patient especially when hospitalized for pyelonephritis. Ciprofloxacin used to be a popular choice for urinary tract infection. Because of overuse, rates of resistance are now about the same as for Bactrim, but remember, ciprofloxacin and all the fluoroquinolones have a black box warning for children.

04:54 This is not because of tendonitis so much but this is mostly because of peripheral neuropathy and other side effects where we worry about in children and adults. So, this would be a poor first choice agent for a patient with UTI. That said, I’ve absolutely used it in cases where I got an organism back and that’s the only oral antibiotic that that organism was sensitive to.

05:18 Nitrofurantoin is very effective against E. coli and we often use it. However, remember, it does not help for patients with pyelonephritis. So, if your patient has suspected pyelonephritis, you may not use nitrofurantoin, it’s only for cystitis. So, who would you not use it in? You would not use it in infants under 1 because those children are nonspecific in their presentation and may well have a pyelonephritis and you should not use it in patients with costovertebral angle tenderness to palpation. Those patients probably have a pyelo and nitrofurantoin would be a bad choice. For infants hospitalized with a UTI, we will do broad-spectrum antibiotics. So, an example would be ampicillin and gentamicin. This treats most, but not all, of E. coli. Very rarely, we see an extended spectrum beta-lactamase producing organism like an E. coli or a Klebsiella that is resistant to ampicillin and gentamicin, but this is a good choice for a neonate as is ampi and ceftriaxone. Remember, ceftriaxone only for children over 1 month because of concerns of of kernicterus but under a month we can use another third generation cephalosporin such as cefotaxime, they’re roughly equivalent. Another option is just cefrtiaxone alone. It’s unclear if we really need the ampicillin routinely if we’re sure this is a urinary tract infection. However, while this treats almost all E. coli, this would miss Enterococcus. That’s a key thing to remember.

06:59 Enterococcus is resistant to third generation cephalosporins. We need to add the ampicillin to cover Enterococcus. It’s true this would miss Listeria but Listeria UTIs in infants are exceptionally rare and some would say they’re literally gone from the United States. So, you probably don’t need it for Listeria coverage. In adults, we can use short-duration therapy for urinary tract infections. Children are different. You cannot use short-duration antibiotics in children because they have rebound recurrent UTIs. So, an infant who has a UTI should be treated for 10 to 14 days. Children who are over 2 years with a severe infection should be treated for 7 to 14 days and it’s only until over 6 years that we feel comfortable using shorter courses of therapy for cystitis.