By Caroline Frost, PharmD candidate
Urinary tract infections (UTIs) are a common childhood infection. About 90% of pediatric UTIs occur in females.1 Uropathogenic Escherichia coli accounts for about 80% of UTIs in children, specifically 83% in females and 50% in males. Other uropathogens include Enterococcus species (5% females, 17% males), Proteus mirabilis (4% females, 11% males), and Klebsiella sp (4% females, 10% males).2 Uropathogen invasion can lead to kidney inflammation and scarring as well as impaired kidney function.3
Urine cultures alone cannot be used to diagnose a UTI, UTICalc is a validated calculator developed to incorporate symptoms and risk factors in those 2-23 months of age to determine if testing is needed and if so if it is best to begin empiric therapy.4 A UTI with fever suggests a systemic infection, potentially pyelonephritis, which could result in kidney injury.3 Those with febrile UTI should usually be treated right away to prevent kidney injury from occurring.3
The American Academy of Pediatrics (AAP) retired their last iteration of their guidelines for infant UTIs (i.e., ages 2 to 24 months) in May 2021 and there have not been national guidelines for those 2 – 12 years.5 The recommended duration of antibiotic therapy in the retired AAP guidelines suggested 7 to 14 days (with no preference between them as data comparing 7,10, and 14 days were limited), with 7 days as the minimum due to 1 to 3 day durations shown to be inferior.5 The AAP’s general infectious diseases recommendations in the 2024 Redbook recommends 5-10 days for outpatient UTI treatment, 7-10 days for inpatient UTI treatment, and for those adolescents with simple cystitis only 3-5 days duration.6
Where did these shorter durations come from?
New data have been published on the duration of antibiotic treatment for pediatric UTIs in recent years. A retrospective cohort analysis published in January of 2020 evaluated the association of antibiotic treatment duration with recurrence of uncomplicated UTI in pediatric patients.7 This study utilized data from a claims database from 2013-2015 and included 7,698 pediatric patients 2 to 17 years old diagnosed with acute cystitis or acute pyelonephritis in an ambulatory setting that filled a prescription for either amoxicillin with or without clavulanate, ampicillin, a cephalosporin (any), trimethoprim-sulfamethoxazole, ciprofloxacin, levofloxacin, or nitrofurantoin with a 7, 10, or 14 day supply.7 Prescriptions for a 3 to 5 day supply were only included if they were for a diagnosis cystitis.7 Authors reported that no difference was seen in recurrence/reinfection rates when comparing 7 days to 10 days and comparing 7 days to 14 days were compared (compared to 7 days: 10 days, OR 1.07, 95% CI 0.85-1.33; 14 days, OR 0.89, 95% CI 0.45-1.78).7 These findings suggest a 7 day course of antibiotics is not associated with increased risk of relapse or reinfection in cases of pediatric cystitis and pyelonephritis. It supports avoiding longer duration of antibiotic treatment in these patients 2 – 17 years old.
A meta-analysis published in December 2024 further evaluated short-course therapy compared with standard-course durations for children with UTI.8 The meta-analysis included 9 randomized controlled trials (n=1,171 pediatric patients < 18 years old) that evaluated efficacy of short-course (2-5 days) versus standard-course (6-14 days) treatment for acute UTI (including afebrile and febrile UTI) in children 2 months to 18 years of age.8 The authors reported that those randomized to short-course therapy had a 2.2% higher risk of treatment failure, but this difference was significant only for those who presented without fever (3.8% increased risk in this group).8 However, due to unexplained heterogeneity between studies and a small number of children across studies presenting with febrile UTI, the data are not clear enough to suggest short-course therapy in pediatric patients presenting with febrile UTI despite this outcome.8 This meta-analysis also reported no significant difference between treatment groups in UTI and bacteriuria 25-60 days after completing treatment.8 In summary, this study provides further evidence to support shorter durations of antibiotics for children with UTIs. The SCOUT trial was a randomized clinical noninferiority trial published in June 2023 that included patients ages 2 months to 10 years old with symptomatic UTI.9 While this trial was included in the 2024 meta-analysis previously discussed, its focus on children 2 months to 10 years old makes it important to view the specific data in this very young but important age group. Six hundred ninety-three children were included and randomized to either 10 or 4 days (plus 5 days placebo) therapy.9 Importantly, inclusion was determined at day 5 and only in those who showed signs of clinical improvement.9 Authors reported rates of treatment failure 0.6% 5 days vs 4.2% 10 days and recurrence within 9 days of study product discontinuation 2.7% 5 day vs 4.2% 10 day treatment groups.9 Although 5 days of therapy was statistically inferior to the standard 10 day durations, the authors noted those who were likely to fail had uncomplicated disease (e.g., UTI without fever) and unlikely to have their UTI associated with scarring 9. They calculated that the number of patients needed to treat to prevent one febrile UTI treatment failure was 67 and more importantly, quite a large number, 469 patients, exactly, would need to be treated to prevent one child from having kidney scaring.9 Looking at all of the information in context, the authors suggest that short-course antibiotics could be a reliable option for children 2 months – 10 years old with UTI with or without fever who demonstrate clinical improvement after 5 days of antibiotics.9 The evidence gathered from these three articles suggests that 5 to 7 day durations for antibiotics can be a consideration for the treatment of pediatric UTIs.
What other options can be considered?
There has also been discussion of single dose aminoglycoside therapy for UTIs. A 2018 systematic review evaluated single dose aminoglycoside therapy (i.e., netilmicin, gentamicin, amikacin) using 13 articles representing 13,804 patients, 53.8% of which were children.10 Articles that studied pediatrics included ages 2 weeks to 16 years old (except one article that did not report age of participants).10 Most of the pediatric specific studies included those with afebrile UTI. Microbiological cure was reported to be 84.5% +/- 4.3% with a 19.0% rate of 30 day recurrence.10 Only 2 studies included evaluated clinical cure, with clinical cure rates of 82.8% and 94.7%.10 This systematic review suggests that single dose aminoglycoside therapy may be reasonable for pediatric patients presenting with afebrile UTI.10 There was no recommendation for single dose aminoglycosides in the AAP 2011 guidelines at all, so this would be an extension to the guidelines if implemented. Single dose aminoglycoside therapy could be beneficial for patients who are not likely to be adherent to multiple days of outpatient oral medications. However, due to lack of robust data for pediatric patients, I think clinicians in most cases should wait for more data specific to pediatrics before implementing single dose aminoglycoside therapy for pediatric patients.
But What About WikiGuidelines?
In response to new evidence, A WikiGuidelines Group Consensus Statement was published in November 2024 and provided recommendations that included treatment of pediatric UTI.11 Unfortunately, due to the limited amount of pediatric specific data they were unable to make a clear recommendation on duration of treatment in pediatric UTI.11 It suggested that shorter courses, including an option for single dose aminoglycosides, may be comparable to longer courses and considered reasonable for afebrile UTI in children >2 months old with low likelihood of pyelonephritis.10 Regarding treatment of pyelonephritis, it is stated that available data is inadequate to provide any recommendation for children >2 months old, but data suggests similar clinical success with 5-9 days versus 10-14 days of treatment.11
Summary
Overall, newer evidence suggests that shorter durations of antibiotic therapy is likely reasonable for pediatric afebrile UTI. The data for treatment duration in febrile UTI is less uncertain, the AAP Redbook recommend a range of 5 to 10 days for treatment of outpatients and 5 -10 days for treatment of inpatients, it is likely safe to lean towards the 7 days of therapy as opposed to 10 days or longer for those with fever. From the data gathered across these newer studies, 5 days of therapy is may be considered for afebrile UTI in pediatric patients that are clinically improving by day 5.
Antibiotic Durations for Pediatric UTIs: What’s Changing?
| Guideline Recommendation | Recent Evidence | Potential Change |
| 2011 AAP Guidelines (retired): (2 – 24 months) 7–14 days for cystitis and pyelonephritis
2024 Wikiguidelines: (> 2 months) limited data consider 3–5 days for cystitis; 5–9 days for pyelonephritis
2024 AAP Red Book: (not neonate) 5–10 days for outpatient UTIs; 7–10 days for inpatient UTIs; 3–5 days for simple cystitis in adolescents (longer if complicated) |
2020 Retrospective cohort (ages 2–17 yrs): Duration not linked to relapse or recurrence (3–5 days for cystitis; 7 days for pyelonephritis)
2024 Meta-analysis (ages <18 yrs): Short-course (2–5 days) may be reasonable for afebrile UTIs |
Consider 5 days for acute cystitis and 7 days for acute pyelonephritis in those 2 months and older. (Additional durations may still be needed if not clinically improved or for complicated disease) |
About the author: Caroline Frost is a Doctor of Pharmacy candidate at the University of Connecticut. This post was written as part of her Advanced Pharmacy Practice Experience under the guidance of her professor, Jennifer Girotto PharmD, BCPPS, BCIDP, who also reviewed and edited the piece.
References
1. Sood A, Penna FJ, Eleswarapu S, et al. Incidence, admission rates, and economic burden of pediatric emergency department visits for urinary tract infection: Data from the nationwide emergency department sample, 2006 to 2011. J Pediatr Urol. 2015;11(5):246.e1–246.e8. doi: 10.1016/j.jpurol.2014.10.005.
2. Edlin RS, Shapiro DJ, Hersh AL, Copp HL. Antibiotic resistance patterns of outpatient pediatric urinary tract infections. J Urol. 2013;190(1):222–227. doi: 10.1016/j.juro.2013.01.069.
3. Mobley HLT, Donnenberg MS, Hagan EC. Uropathogenic escherichia coli. EcoSal Plus. 2009;3(2):10.1128/ecosalplus.8.6.1.3. doi: 10.1128/ecosalplus.8.6.1.3.
4. Marsh MC, Junquera GY, Stonebrook E, Spencer JD, Watson JR. Urinary tract infections in children. Pediatr Rev. 2024;45(5):260–270. doi: 10.1542/pir.2023-006017.
5. Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management, Roberts KB. Urinary tract infection: Clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics. 2011;128(3):595–610. doi: 10.1542/peds.2011-1330.
6. Systems-based treatment tableCommittee on Infectious Diseases, American Academy of Pediatrics, Kimberlin DW, Banerjee R, Barnett ED, Lynfield R, Sawyer MH, eds. Red book: 2024–2027 report of the committee on infectious diseases. American Academy of Pediatrics; 2024:0. https://doi.org/10.1542/9781610027373-TAB. Accessed 7/17/2025. 10.1542/9781610027373-TAB.
7. Afolabi TM, Goodlet KJ, Fairman KA. Association of antibiotic treatment duration with recurrence of uncomplicated urinary tract infection in pediatric patients. Ann Pharmacother. 2020;54(8):757–766. doi: 10.1177/1060028019900650.
8. Mueller GD, Conway SJ, Gibeau A, Shaikh N. Short- versus standard-course antimicrobial therapy for children with urinary tract infection: A meta-analysis. Acta Paediatr. 2025;114(3):479–486. doi: 10.1111/apa.17546.
9. Zaoutis T, Shaikh N, Fisher BT, et al. Short-course therapy for urinary tract infections in children: The SCOUT randomized clinical trial. JAMA Pediatr. 2023;177(8):782–789. doi: 10.1001/jamapediatrics.2023.1979.
10. Goodlet KJ, Benhalima FZ, Nailor MD. A systematic review of single-dose aminoglycoside therapy for urinary tract infection: Is it time to resurrect an old strategy? Antimicrob Agents Chemother. 2018;63(1):e02165–18. Print 2019 Jan. doi: 10.1128/AAC.02165-18.
11. Nelson Z, Aslan AT, Beahm NP, et al. Guidelines for the prevention, diagnosis, and management of urinary tract infections in pediatrics and adults: A WikiGuidelines group consensus statement. JAMA Netw Open. 2024;7(11):e2444495. https://doi.org/10.1001/jamanetworkopen.2024.44495. Accessed 7/7/2025. doi: 10.1001/jamanetworkopen.2024.44495.