Urinary Tract Infections - Community Onset

Patient Population: Pediatric

See further UTI management guidelines from the UCSF Northern California Pediatric Hospital Medicine Consortium, though reference below recommendations for updated antibiotic selection.

Diagnosis is made based on: 

Pyuria (>5-10 WBC/HPF on microscopy) AND 

At least 50,000 colonies per mL of a single uropathogenic organism in an appropriately collected specimen: 

Catheterized (even if bag collection for urinalysis is used for screening, catheterization should be used to collect urine for culture) 

Clean catch  

Compatible urinary tract symptoms 

Therapy should be modified according to culture and susceptibilities.  For patients with prior UTIs, consider susceptibilities of prior causative organisms when selecting empiric therapy. See Table 1 for inferred susceptibility for enteral antibiotics from IV antibiotic susceptibilities that are routinely reported in BCH Microbiology laboratories. Consider ID/ASP consult for patients with current or recent history of multidrug resistant organisms, such as Extended-Spectrum Beta-lactamase (ESBL) producers. 

Condition Major Pathogens  First Choice Therapy Alternative Therapy Comments
Urinary tract infection < 2 months old   Enteric gram-negative bacteria 

In most cases therapy will be initiated per Fever Without a Source - Young Infant guidelines 

In infants age 28-60 days, if initial evaluation indicates UTI is likely (pyuria on urinalysis), initial oral therapy may be appropriate based on evaluating provider discretion. 

For infants initially treated with IV therapy, conversion to pathogen-directed enteral therapy is appropriate in most cases after resolution of presenting signs and symptoms of UTI. 


Urinary tract infection, community-onset, 2 months-12 years old 

 Includes febrile UTI in which involvement of upper vs. lower urinary tract cannot be easily distinguished 

Enteric gram- negative bacteria  Cephalexin
25 mg/kg/dose (max 500 mg/dose) enterally tid 

Penicillin or cephalosporin allergy with higher risk for allergic reaction OR history of prior UTI with cefazolin resistant, Trimethoprim-sulfamethoxazole susceptible organism

Trimethoprim-sulfamethoxazole (Bactrim) 5 mg trimethoprim/kg/ dose (max 160 mg trimethoprim/dose) enterally bid

Duration: 7 days 

Modify therapy based on culture and susceptibilities 

Note: Ceftriaxone does NOT predict cefdinir, cefixime or cefpodoxime susceptibility (See Table 1 below for inferred susceptibilities) 

Uncomplicated cystitis, > 12 years old  Enteric gram-negative bacteria  Nitrofurantoin monohydrate/ macrocrystals (Macrobid)
100 mg/dose enterally bid 
25 mg/kg/dose (max 500 mg/dose) enterally bid  

Duration: 3-5 days 

Modify therapy based on culture and susceptibilities 

Pyelonephritis, community-onset, > 6 months of age   Enteric gram-negative bacteria 


50 mg/kg/dose (max 1000 mg/dose) IV q24h  


If candidate for enteral therapy

25 mg/kg/dose (max 500 mg/dose) enterally tid  

Penicillin or cephalosporin allergy with higher risk for allergic reaction


10 mg/kg/dose (max 400 mg/dose) IV q8h 


If candidate for enteral therapy

15 mg/kg/dose (max 500 mg/dose) enterally bid 

ID consult recommended for complicated infection, concurrent bacteremia, or inadequate response to initial therapy 

Consider Urology consult if patient has urinary tract abnormalities 

Duration:  7 days for most patients, individualized per ID consult guidance for patients with significant complications  

Transition IV to enteral once patient is able to tolerate enteral route. 

Modify therapy based on culture and susceptibilities. See Table 1 and Table 2 below. 


Table 1: IV to enteral inferred susceptibility
Ampicillin → amoxicillin (cannot infer susceptibility to cephalosporins) 
Ampicillin-sulbactam (Unasyn) → amoxicillin/clavulanate (Augmentin) 
Cefazolin MIC <=16 → cephalexin/cefuroxime/cefdinir (cephalexin preferred) 
Ceftazidime/Ceftriaxone → N/A (cannot infer susceptibility to 3rd generation oral cephalosporins) 
Ciprofloxacin → ciprofloxacin 
Trimethoprim-sulfamethoxazole → trimethoprim-sulfamethoxazole (Bactrim or Septra) 
Table 2: Prefered enteral antibiotics for definitive therapy 

If the patient is able to take enteral therapy and the bacteria is susceptible, recommend narrowing antimicrobial coverage (the following antibiotics are in order of preferential use top to bottom): 

1st Tier 

Amoxicillin 25 mg/kg/dose (max 500 mg/dose) enterally bid 


Cephalexin 25 mg/kg/dose (max 500 mg/dose) enterally tid  

2nd Tier 

Trimethoprim-sulfamethoxazole (Bactrim or Septra) 5 mg trimethoprim/kg/dose (max 160 mg trimethoprim/dose) enterally bid  


Nitrofurantoin monohydrate/macrocrystals (Macrobid) (only use in cystitis without pyelonephritis) 100 mg/dose enterally bid

3rd Tier                    

Amoxicillin-clavulanate (Augmentin) 25 mg amoxicillin/kg/dose (max 500 mg amoxicillin/dose) enterally bid 

Exception: ESBL-producing organism, move to 4th tier for clinically stable outpatient, otherwise contact ASP for guidance about other options.

4th Tier Ciprofloxacin 15 mg/kg/dose (max 500 mg/dose) enterally bid 


American Academy of Pediatrics Subcommittee on Urinary Tract Infection. 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;128:595-610. 

CLSI supplement M100. Wayne, PA: Clinical and Laboratory Standards Institute; 2020. 

Fox, M. T., Amoah, J., Hsu, A. J., Herzke, C. A., Gerber, J. S., & Tamma, P. D. (2020). Comparative effectiveness of antibiotic treatment duration in children with pyelonephritis. JAMA Network Open, 3(5), e203951. 

Gupta K, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis 2011;52:e103-e120. 

American Academy of Pediatrics. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. 32nd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2021.  

Pediatric Empiric Antimicrobial Therapy Guidelines

This is a subsection of the UCSF Benioff Children’s Hospitals Empiric Antimicrobial Therapy Guidelines, developed by the Pediatric Antimicrobial Stewardship Programs at each campus to inform initial selection of empiric antimicrobial therapy for children at the UCSF Benioff Children’s Hospitals and affiliated outpatient sites. 

These are guidelines only and not intended to replace clinical judgment. Modification of therapy may be indicated based on patient comorbidities, previous antibiotic therapy or infection history. Doses provided are usual doses but may require modification based on patient age or comorbid conditions. Refer to Pediatric Antimicrobial Dosing Guideline for further guidance on dosing in children, and Neonatal Dosing Guideline for infants < 1 month of age. Consult a pediatric pharmacist for individualized renal or hepatic dose adjustment. Durations provided are usual recommendations for patients who are responding appropriately to therapy. For additional guidance, please contact Pediatric Infectious Diseases (ID) or the Pediatric Antimicrobial Stewardship Program (ASP) at the campus where your patient is receiving care.  

For questions or feedback about these guidelines, please email primary content owners, Rachel Wattier, Pediatric ASP Medical Director at BCH SF and Prachi Singh, Pediatric ASP Medical Director at BCH OAK. 

The content of these guidelines was updated in July 2021. See Summary and Rationale for Changes (password login to Box needed) for detailed explanations of the content changes.