Table 1.

Summary of UTI management (AST: antimicrobial susceptibility testing)

A. Procedures and investigations
Age	Choices	Alternative
Urine collection
≤ 90 days	Catheterization/clean catch	Suprapubic aspiration
> 90 days	Clean catch/catheterization	Suprapubic aspiration, collection bag (only for exclusion of UTI)
Urine testing and culture
≤ 90 days	Urine analysis and Culture
> 90 days	Urine analysis	Culture if positive dipstick (Leukocyte esterase and/or nitrite) or pyuria on microscopy
Independent of age
Septic patient	Urine analysis and culture
Recurrent UTI	Urine analysis and consider culture
Clinical signs and symptoms not correlating with urine analysis results: Culture
Additional laboratory testing (to consider)
≤ 90 days	CRP and/or PCT, complete blood count, blood culture, plasma creatinine, sodium (Na), potassium
> 90 days	CRP and/or PCT
Independent of age
Septic patient, neonates	Full sepsis workup (blood, urine and cerebrospinal fluid investigations and cultures)
B. Empiric therapy UTI
	≤ 30 days	31–60 days	From 61 days (> 2 months)	From 180 d (6 months)
Fever (> 38 °C) Pyelonephritis	Amoxicillin + aminoglycoside IV	Amoxicillin + ceftriaxone IV	Oral: amoxicillin-clavulanate or 3rd gen. cephalosporine
Treatment duration	7–10 days	7–10 days	7–10 days
Route	IV Switch to an oral antibiotic may be considered in line with AST: - If good clinical response, tolerating oral feeding - No meningitis - No sepsis at presentation - After at least 3 days iv	Start IV and switch to oral Switch to an oral antibiotic (in line with AST) if good clinical response; if sepsis at presentation consider full 7–10 days iv or may switch to oral after 3 days iv with improved general state and tolerating oral feeding	Oral Start IV (ceftriaxone) if poor general condition or unable to tolerate oral feeding
Afebrile Cystitis				Oral: trimethoprim-sulfamethoxazole or amoxicillin-clavulanate
Treatment duration				3 days
Route				Oral
C. Reassessment after initiation of treatment
All children should be reassessed on days 3 to 5 following UTI diagnosis for (i) clinical (and possibly laboratory) response to treatment, (ii) confirmation of the diagnosis, and (iii) possibly adaptation of the therapy according to the AST (aim: narrowing antimicrobial spectrum)
Treatment should be ceased if the UTI diagnosis is not confirmed (in case of a negative urine culture).
Repeat urine testing is only needed if no adequate response to treatment is seen (consider complications or other differential diagnoses).
D. Follow-up investigations
All children experiencing a first episode of UTI (excluding afebrile UTI in children > 180 days) should be investigated by ultrasound of the kidneys and urinary tract within 6 weeks of the diagnosis
MCUG should only be performed in children with any of the following risk factors: CAKUT, abnormal ultrasound suggesting anatomical pathology, non-E. coli UTI, sepsis, inadequate response to treatment within 48 h, signs of chronic kidney disease (increased creatinine or dyselectrolytemia (sodium, potassium) or elevated blood pressure), poor urine flow, recurrent (febrile) UTIs
E. Antibacterial prophylaxis
Prophylaxis only to be considered in VUR grades IV and V (WHO grading I–V). If MCUG is indicated, antibiotic prophylaxis may be started and continued up to the examination.