Antibiotic Stewardship in Pediatric Urinary Tract Infections: Current Evidence and Practical Strategies

Background/Objectives: Urinary tract infections (UTIs) are among the most common bacterial infections in children and represent a leading indication for antibiotic prescribing across inpatient, emergency department, and outpatient settings. Despite the availability of multiple international guidelines, prescribing practices for pediatric UTI frequently deviate from evidence-based recommendations in antibiotic selection, route of administration, and duration of therapy. These suboptimal practices contribute to the emergence of resistant uropathogens, including extended-spectrum β-lactamase-producing organisms, and highlight the need for a comprehensive stewardship approach specific to this population. Methods: A literature search was performed using PubMed and MEDLINE from January 2000 to May 2026 using the following search terms: urinary tract infection, children, pediatrics, antibiotic stewardship, antimicrobial resistance, diagnosis, treatment, duration, prophylaxis, and intravenous-to-oral transition. Thirteen active international guidelines published between 2011 and 2025 were identified and evaluated with specific emphasis on the integration of antibiotic stewardship principles. Clinical trials, systematic reviews, meta-analyses, and quality improvement studies addressing stewardship-relevant outcomes in pediatric UTI were included. Case reports were excluded. Results: Comparative analysis of 13 international UTI treatment guidelines demonstrated substantial variation in diagnostic criteria, treatment duration, and prophylaxis recommendations, with most guidelines predating the SCOUT, STOP, and INDI-UTI randomized controlled trials. Diagnostic stewardship interventions targeting urine collection methods, urinalysis-guided treatment decisions, and avoidance of antibiotic treatment for asymptomatic bacteriuria represented high-impact opportunities to reduce unnecessary antibiotic exposure. Oral antibiotic therapy was as effective as intravenous therapy for most children with pyelonephritis, and early intravenous-to-oral transition was supported by consistent randomized controlled trial evidence. A 5-day oral course may be reasonable for uncomplicated febrile UTI in children demonstrating clinical improvement, supported by the STOP trial, although the SCOUT trial did not meet its noninferiority margin despite a low absolute failure rate; 3 to 5 days was appropriate for uncomplicated cystitis. Antibiotic prophylaxis was not indicated in children with a normal urinary tract following a first febrile UTI and should be reserved for specific high-risk subgroups, with nitrofurantoin as the preferred agent. Formal antibiotic stewardship programs combining prospective audit and feedback, electronic health record integration, and prescriber education demonstrated measurable improvements in prescribing appropriateness for pediatric UTI. Gepotidacin, a first-in-class oral antibiotic approved in 2025 for uncomplicated UTI in female patients aged 12 years and older and weighing at least 40 kg, represented a limited option for eligible adolescents with resistant infections. Conclusions: Antibiotic stewardship for pediatric UTI addresses the full clinical pathway from diagnostic stewardship through prophylaxis rationalization. Evidence-based interventions targeting urine collection, urinalysis-guided decision-making, early intravenous-to-oral transition, duration optimization, and selective prophylaxis use can collectively reduce unnecessary antibiotic exposure without compromising patient outcomes. A dedicated stewardship-oriented pediatric UTI guideline, standardized resistance surveillance, and multicenter stewardship program evaluations with patient-centered outcomes are critical research priorities.