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 |
Ceftazidime 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) Penicillin or cephalosporin allergy with higher risk for allergic reaction: Ciprofloxacin OR 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 OR 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 OR 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 Exception: ESBL-producing organism, contact ASP for guidance. |
|||
| 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 OR 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 Exception: ESBL-producing organism, contact ASP for guidance. OR Ceftriaxone 50 mg/kg/dose (max 1000 mg/dose) IV q24h OR 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 | |||
References:
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.