UTI Clinical Guidelines

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UTI Clinical Guidelines

Patient meets admit criteria?

Test of Cure cultures at 48 hours NOT recommended

Definite UTI

  • Clean catch: Urine culture >/= 100,000 CFU
  • Cath specimen: Urine culture >/= 50,000 CFU

Presumed or definite UTI?

Other considerations

VCUG if:

  • Atypical UTI
  • RBUS shows hydronephrosis, kidney size discrepancy, renal parenchymal loss
  • 2nd febrile UTI even if RBUS normal

Refer to Urology

Presumed UTI

  • Infants/Non-toilet trained: +clinical features of UTI regardless of UA results
  • Toilet trained/Adolescents: +clinical feature of UTI and positive UA (+nitrites, +leuk esterase, + bacteria, or > 10 wbc/hpf)

Inclusion Criteria
  • Birth to 18 years (corrected GA > 40 weeks)
  • Presumed or definite UTI
Exclusion Criteria
  • Prior history of UTI
  • Chronic kidney disease
  • Known GU abnormalities (eg, VUR)
  • Septic shock or need for ICU care
  • Presumed meningitis
  • Immunocompromised patient
  • Recent history of sexual abuse
  • Pregnancy

Toilet-trained children and Adolescents

  • Midstream clean catch
  • Girl/uncircumcised boy: test if >/= 1
  • Circumcised boy: test if >/= 2
  • Abdominal pain, Back pain, Dysuria, Frequency, New-onset incontinence, Fever > 40C

RBUS if:

  • All infants and non-toilet trained children
  • Toilet trained boys with 1st UTI
  • Toilet trained girls with atypical UTI
  • No clinical improvement in 48 hours (start with RBUS, may need CT to detect perinephric abscess)

Obtain when hospitalized, if no improvement, or at 4-6 weeks if outpatient.

Consider additional

  • Annual HIV testing
  • GC/CT urine, RPR serum

Outpatient treatment

Age 2-12 months: Cephalexin 25 mg/kg/dose TID x 7 days (non-febrile) or x 10 days (febrile)

  • Bactrim/Septra 4 mg/kg/dose BID if beta-lactam allergy

Adolescents > 12 yo: Cephalexin 25 mg/kg/dose BID (max 500 mg/dose) x 7 days (3 days if cystitis only)

  • Alternative: Nitrofurantoin 100 mg/dose BID x 5 days (only if no pyelonephritis, does not penetrate renal parenchyma)

If you order clean catch for non-toilet trained children:

  • If negative, OK to monitor without antibiotics
  • If positive, need to send new catheter specimen for culture

Decision to test?

Admit Criteria

  • Age 0-30 days
  • Age 31-60 days if febrile
  • Dehydration requiring IV fluids
  • Failed outpatient therapy
  • Risk of non-adherence


  • Always catheterize

Test if any of the following:

  • Febrile, Prolonged jaundice, Irritability, emesis

Non-toilet trained children

  • Ideally Catheterize

Girl/Uncircumcised boy: test if 1yo

Circumcised boy: test if 2yo OR suprapubic tenderness

  • Ill-appearing, Suprapubic tenderness, Fever > 24 hours, Fever > 39C, No source

Inpatient treatment

Infants 0-30 days: IV Ampicillin + Gentamicin OR IV Ampicillin + Cefotaxime

  • Narrow coverage when ID & sensitivities return
  • Consult ID, may be able to transition to PO antibiotics at 7 days
  • Treat for 14 days total

Infants 31-60 days: IV Ceftriaxone

  • Use Ampicillin + Gentamicin if enterococcus is suspected
  • Switch to PO when afebrile x 24 hours and negative blood culture x 36 hours
  • Narrow coverage when ID & sensitivities return
  • Treat for 14 days total

All other ages: IV Ceftriaxone

  • Use Ampicillin + Gentamicin if enterococcus is suspected
  • Switch to PO, narrow coverage when ID & sensitivities return
  • Treat for 7-10 days total

Discharge criteria

  • Afebrile x 24 hours
  • Clinical response to treatment
  • Able to maintain hydration
  • Urine culture negative OR culture positive and on targeted antibiotics
  • Studies for bacteremia/meningitis negative (if applicable)
  • If indicated, Urology follow-up and VCUG scheduled

Refer to Urology if:

  • < 6 yo with recurrent UTI
  • Abnormal imaging (PUV, grade III-V VUR, ureterocele, duplex system, kidney size discrepancy, parenchymal abnormality)

Consult PICU or sub-specialists as needed

Antibiotic prophylaxis if:

  • VCUG is indicated
  • High grade VUR (IV-V)

Age < 2 mos: Amoxicillin 20 mg/kg once daily (max 500 mg) OR Cephalexin 10 mg/kg once daily (max 250 mg)

Age > 2 mos: Bactrim/Septra 2 mg/kg once daily (max 80 mg)


1) John Muir Medical Center UTI Clinical Practice Guideline. Internal document.

2) Seattle Children's UTI Pathway v7.0. http://www.seattlechildrens.org/pdf/uti-pathway.pdf.

3) Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months. American Academy of Pediatrics, 2011. https://pediatrics.aappublications.org/content/pediatrics/early/2011/08/24/peds.2011-1330.full.pdf.

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