An update on new antibiotic prophylaxis and treatment for urinary tract infections in children

ABSTRACT

Introduction: This review focuses on the treatment of urinary tract infections (UTI) in children and in particular its recent changes.

Areas covered: Acute pyelonephritis, acute cystitis and asymptomatic bacteriuria or asymptomatic infections have to be clearly distinguished. Prompt treatment is required in pyelonephritis and cystitis, but not in asymptomatic bacteriuria or infection, in order to avoid selection of more virulent strains. This concept should be considered even in immunocompromised or bedridden children. In case of pyelonephritis, there should be no delay in beginning the antibiotic treatment in order to decrease the risk of long term complication, such as renal scars. Predisposing conditions for UTI, such as voiding anomalies and urinary tract malformation should be carefully evaluated.

Expert opinion: One major concern is the increasing resistance to 3^rd generation cephalosporins. Therefore overconsumption in low-risk settings should be absolutely avoided. The prevalence of infections with E. coli producing extended spectrum ß-lactamase (ESBL) is increasing and pediatricians should be aware about the specific treatment options. Any recommendation about (initial) antibiotic treatment should be regularly updated and adapted to local resistance profiles and to economic factors in different health systems.

KEYWORDS:

• Urinary tract infection
• pyelonephritis
• children
• antibiotic resistance
• treatment
• asymptomatic urinary tract infection
• asymptomatic bacteriuria

Article highlights

• The proportion of multiresistant bacteria including ESBL is steadily increasing since recent years, even in patients without associated risk factors, and this situation requires awareness among pediatricians.

• In order to avoid the emergence of ESBL, we advise treating acute pyelonephritis with aminoglycoside IV during at least 48 h before switching to oral antibiotics in younger children or in case of suspected or proven uropathy.

• In infants older than 4–6 months of age, an initial oral treatment with 3rd-generation cephalosporin and amoxicillin/clavulanic acid or cotrimoxazole can be considered, if no severity criteria such as urosepsis, vomiting or urinary obstruction are detected.

• The use of prophylactic antibiotics is individualized: patients after a first febrile UTI and anomalies of the urinary tract detected on ultrasound are treated with trimethoprim–sulfamethoxazole (cefaclor in the first month of life) until their VCUG and only in case of VUR detection the antibiotic is maintained. UTI recurrence may require a surgical procedure.

• In case of cystitis, cephalosporins should be avoided if possible and reserved for the treatment of pyelonephritis.

• Asymptomatic bacteriuria and asymptomatic UTI should not be treated, even in immunocompromised and bedridden patients, but the detection of a specific bacteria may guide the first line therapy in symptomatic UTI later in due course.

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Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Additional information

Funding

This paper was not funded.