What are the AAP guidelines on antibiotic selection for the treatment of pediatric urinary tract infection (UTI)?

Updated: Mar 19, 2019
  • Author: Donna J Fisher, MD; Chief Editor: Russell W Steele, MD  more...
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If clinical findings indicate that immediate antibiotic therapy is indicated, a urine specimen for urinalysis and culture should be obtained before treatment is started. Specimens may be collected by means of suprapubic aspiration or catheterization.

A study by Shaikh et al analyzed data for 482 children (age, 2 - 72 months) with a first or second UTI to determine whether delay in the initiation of antimicrobial therapy for febrile UTIs is associated with the occurrence and severity of renal scarring. The study found that a total of 35 children (7.2%) developed new renal scarring and that this renal scarring was significantly associated with a delay in the initiation of antimicrobial therapy. [47, 48]

According to AAP guidelines for the treatment of initial UTIs in febrile infants and children aged 2-24 months old, antibiotics can be given orally or parenterally, with the choice of route based on practical considerations. [3] Oral antibiotics should not be used in a child who is acutely ill or toxic, has persistent vomiting, or has moderate to severe dehydration. Daily follow-up and good compliance are essential with this approach.

The AAP recommends basing the choice of antibiotic on local sensitivity patterns, if known. The choice can be adjusted, if necessary, when results of sensitivity testing become available. Antibiotics can be given for 7 or 14 days. [3]

Common choices for empiric oral treatment are a second- or third-generation cephalosporin, amoxicillin/clavulanate, or sulfamethoxazole-trimethoprim (SMZ-TMP). (See Table 4, below). A Canadian retrospective chart review of 173 pediatric patients diagnosed with a clinical UTI found that if the urinalysis is positive for nitrites, 1.4% of pathogens were resistant to third-generation cephalosporin, and 8.4% were resistant to first-generation cephalosporins. [49]

Table 4. Antibiotic Agents for the Oral Treatment of Urinary Tract Infection (Open Table in a new window)


Daily Dosage

Sulfamethoxazole and trimethoprim (SMZ-TMP)

30-60 mg/kg SMZ, 6-12 mg/kg TMP divided q12h

Amoxicillin and clavulanic acid

20-40 mg/kg divided q8h


50-100 mg/kg divided q6h


8 mg/kg q24h


10 mg/kg divided q12h


5-7 mg/kg divided q6h

*Nitrofurantoin may be used to treat cystitis. It is not suitable for the treatment of pyelonephritis, because of its limited tissue penetration.

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