Urinary Tract Infections - Hospital Onset | Infectious Diseases Management Program at UCSF

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	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) 100 mg piperacillin/kg/dose (max 4000 mg  piperacillin/dose) IV q6h  Penicillin or cephalosporin allergy with higher risk for allergic reaction: Ciprofloxacin 10 mg/kg/dose (max 400 mg/dose) IV q8h  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

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

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)
100 mg piperacillin/kg/dose (max 4000 mg  piperacillin/dose) IV q6h 

Penicillin or cephalosporin allergy with higher risk for allergic reaction:

Ciprofloxacin
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 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.

Urinary Tract Infections