Updated guidance from the American Academy of Pediatrics (AAP) broadens diagnostic and treatment recommendations to include infants and children younger than 5 years, while providing a more practical approach to detecting pediatric urinary tract infections (UTIs), reducing unnecessary use of antibiotics, and removing race-based criteria from risk evaluation.

Published in the AAP’s journal Pediatrics, the guidelines mark the first update to the organization’s UTI recommendations since 2011. Identifying UTIs can be difficult in children when fever is the only symptom and can often be mistaken for viral illnesses.

The updated guidelines have the potential to substantially change how UTIs are detected and managed in children, said Brian Alverson, MD, professor of pediatrics at Johns Hopkins University in Baltimore and chair of the panel that developed the updated recommendations.

“There are many areas where this will change the game, and I am really excited about that game change,” he said.

UTIs are among the most common bacterial infections in young children, occurring in approximately 7% of infants who present with fever, according to the guideline.

Alverson said the decision to expand the age range covered by the guideline was intended to underscore that UTIs remain an important health concern for infants older than 8 days and younger children.

Under the new guidance, clinicians are encouraged to evaluate children for UTI using a combination of symptoms, urinalysis findings, urine culture results, and clinical judgment. Physicians should assess children aged 2-5 years within 72 hours of symptom onset when infection is suspected and evaluate children aged 2-24 months who present with fever without an identifiable source in the same timeframe.

The updated recommendations also place greater emphasis on identifying and addressing constipation and bladder-bowel dysfunction as contributing factors in recurrent UTIs.

“Tons of kids who come in with UTI got it because they were constipated,” Alverson said. “If we don’t address the underlying issues of constipation or bladder-bowel dysfunction, we aren’t doing justice to the child in terms of preventing the disease in the first place.”

The guideline recommends shorter antibiotic treatment courses. Most children should receive no more than 7 days of therapy. For lower-risk children aged 2 years or older, a 3- to 5-day course may be sufficient, while those younger than 2 years generally require at least 5 days of treatment.

The recommendations support oral antibiotic therapy for children older than 28 days and encourage transitioning infants aged 8-28 days from intravenous to oral therapy once clinical improvement is observed.

“There are a lot of opportunities for primary care physicians who are managing kids with UTI to reduce the amount of antibiotics that are prescribed,” Alverson said. “We live in a time when resistant organisms are coming to the fore, and many of those resistant organisms are the types that cause urinary tract infections.”

Removal of Race as Clinical Factor

Among the most notable changes is the removal of race from UTI assessment because of concerns that using the marker is not a biological determinant of disease risk. The organization instead emphasizes individualized clinical assessment.

“In our day and age, when we see someone with a different color of skin, we can’t say a lot about their genetics or their predisposition to a variety of illnesses,” Alverson said.

The change reflects a broader movement across medicine to reevaluate the use of race in clinical algorithms that may reinforce inequities in care. Advocates contend removing race from calculators promotes assessments based on symptoms and overall condition while reducing potential implicit bias.

Amanda North, MD, professor and chief of pediatric urology at Montefiore Health System in Bronx, New York, said having updated UTI guidelines was very important for primary care clinicians who take care of children.

“These guidelines help clear up existing confusion about things like criteria for diagnosing UTIs and duration of antibiotic treatment,” North said.

Steven Ross Johnson is a journalist who covers public health and healthcare delivery issues.