Urinary Tract Infections - Hospital Onset

Patient Population: Pediatric

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, hospital-onset 

This category is intended for catheter-associated infection, or patients with significant prior antibiotic exposure - for patients at low-risk for antibiotic-resistant organisms, refer to Community-Onset UTI section 

Enteric and hospital-acquired gram-negative bacteria including Pseudomonas aeruginosa 

If the patient has an indwelling urinary catheter
or performs clean intermittent catheterization, Enterococcus species and Candida species are more likely to
represent colonization. May consider catheter exchange, continue clean intermittent catheterization every 3 hours or as guided by Urology recommendations

50 mg/kg/dose (max 2000 mg/dose) IV q8h  

Cephalosporin allergy with lower risk for allergic reaction (full dose vs. test dose per Inpatient Beta-Lactam Allergy Guideline)

Piperacillin-tazobactam (Zosyn)
100 mg piperacillin/kg/dose (max 4000 mg  piperacillin/dose) IV q6h  

Penicillin or cephalosporin allergy with higher risk for allergic reaction

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


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

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

Consider Urology consult if patient has genitourinary abnormalities 

Modify therapy based on culture and susceptibility. Change to enteral therapy based on clinical improvement, organism isolated, ability to tolerate enteral therapy. See Table 1, 2 and 3 below for guidance 

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: Preferred 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 160mg trimethoprim/dose) enterally bid  


Nitrofurantoin monohydrate/macrocrystals (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 
4th Tier                            Ciprofloxacin 15 mg/kg/dose (max 500 mg/dose) enterally bid 
Table 3: Preferred IV antibiotics for definitive therapy 
IF the patient still needs IV therapy and the bacteria is susceptible, recommend narrowing antimicrobial coverage (the following antibiotics are in order of preferential use top to bottom): 
1st Tier

Ampicillin 50 mg/kg/dose (max 2000 mg/dose) IV q6h 


Cefazolin 25 mg/kg/dose (max 2000 mg/dose) IV q8h 

2nd Tier

Ampicillin-sulbactam (Unasyn) 50 mg ampicillin/kg/dose (max 2000 mg ampicillin/dose) IV q6h 


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


Trimethoprim-sulfamethoxazole (Bactrim or Septra) 5 mg trimethoprim/kg/dose (max 160 mg trimethoprim/dose) IV q12h  

3rd Tier  Ciprofloxacin 10 mg/kg/dose (max 400 mg/dose) IV q8h  
4th Tier                            Gentamicin 5 mg/kg/dose IV q24h 


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. 

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.