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Can fosfomycin be used for the treatment of Gram-negative urinary tract infections in children?
  1. Rachael Purcell1,
  2. Nelson Wang1,
  3. Amanda Gwee1,2,3
  1. 1 Infectious Diseases Unit, Department of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
  2. 2 Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
  3. 3 Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
  1. Correspondence to Dr Rachael Purcell, Infectious Diseases Unit, Royal Children's Hospital Melbourne, Parkville VIC 3052, Australia; rachael.purcell{at}

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A 5-year-old previously well girl is referred to the emergency department with an extended-spectrum beta-lactamase (ESBL) producing Escherichia coli urinary tract infection (UTI). A midstream urine sample taken by her general practitioner showed nitrites, a leucocyte count of >100×106/L and had cultured >100×106 colony forming units/L E. coli resistant to cephalosporins and amoxycillin-clavulanic acid, only sensitive to amikacin and fosfomycin. The child is afebrile and haemodynamically stable with no clinical signs of pyelonephritis. You wonder if fosfomycin would be an appropriate oral treatment choice in order to avoid admission for intravenous antibiotics.

Structured clinical question

In a child with a UTI due to a Gram-negative bacteria (patient), is oral fosfomycin (intervention) (1) safe and effective, and if so (2) what dose should be used (outcome)?


The MEDLINE (1946 to current), PubMed and Cochrane databases were searched in July 2020 using the keywords fosfomycin, paediatric/pediatric and urinary tract infection/UTI/urinary-pathogen. Results were limited to humans under the age of 18 years. Studies of children that reported the use of oral fosfomycin for the treatment of UTIs were included. Across the three databases, there were 203 manuscripts identified and of these, eight were relevant. References of these publications were reviewed, and no additional relevant studies were identified.


Infections due to multidrug resistant (MDR) bacteria are increasing globally, and in children, treatment is particularly challenging given the lack of dedicated paediatric data on newer antimicrobials. The prevalence of MDR Gram-negative UTIs in children ranges from 5% to 90% depending on the geographical region.1 In children with these infections, access to oral antibiotics is important to prevent unnecessary hospital admission for intravenous therapy. Recently, the ‘recycling’ of older antibiotics has been reported as a strategy to broaden our therapeutic armamentarium against MDR infections.

Fosfomycin is a phosphonic acid derivative with activity against both Gram-positive …

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  • Contributors RP conducted the literature search, interpreted results and drafted the manuscript. NW contributed to the manuscript and result interpretation. AG was involved in interpreting the results and edited through multiple revisions. All authors gave final approval for submission of the manuscript in its current form.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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