Guidelines for Complicated Urinary Tract Infections in Children: A Review by the European Society for Pediatric Infectious Diseases

Background: Complicated urinary tract infections (cUTI) present a challenge to the clinician because of the variety in clinical syndromes included and consequent difficulties in synthesizing evidence. A harmonized definition of cUTI does not exist. In national guidelines, management recommendations for cUTI are often neglected. We aimed to define the four most important controversies and formulate management recommendations for cUTI in children and adolescents.

Methods: The European Society of Pediatric Infectious Diseases Guideline Committee convened a working group of experts from microbiology, pediatric nephrology and infectious diseases with expertise in managing children with UTI. A comprehensive literature review was done using PubMed, Embase and the Cochrane library to find studies in children under 18 years published until December 2024. Four controversies were defined from experience and available evidence. Children with cUTI were categorized into 5 subgroups: anatomical/functional urological abnormalities, multiple UTI recurrences, severe clinical presentation, nonurological underlying conditions and neonates. Respective management guidelines were formulated through the evidence and by consensus of working group members. Recommendations were made using GRADE criteria.

Results: The term cUTI is generally used to define children with UTI with an increased likelihood of failing conventional management. The included 5 subgroups are the most likely to need additional investigations at diagnosis and during the course of infection, initial intravenous antibiotics, longer treatment duration, antibiotic prophylaxis, follow-up imaging and surgical referral. These are detailed for each subgroup.

Conclusions: These comprehensive guidelines offer evidence-graded recommendations specifically for pediatric cUTI, addressing gaps that exist in current guidelines.