OBJECTIVE: The incidence of extended-spectrum beta-lactamases (ESBLs)-producing Escherichia coli (E. coli) infections is rising. This study investigates the antibiotic resistance profiles and risk factors associated with ESBL-producing E. coli in urinary tract infections (UTIs) among hospitalized children, providing a basis for rational clinical management. METHODS: We analyzed the clinical data of 140 children diagnosed with UTIs caused by E. coli at Anhui Provincial Children's Hospital from July 2021 and June 2024 in this retrospective study. RESULTS: Among the 140 E. coli strains isolated, the male-to-female ratio was 1.75:1, with a median age of 7 months. Seventy-five strains (53.6%) were identified as ESBL producers. Non-ESBL-producing strains exhibited the highest resistance to ampicillin (60%) and lower resistance rates to cephalosporins and monobactams. Resistance rates for ampicillin-sulbactam, piperacillin-tazobactam, and cefoperazone-sulbactam were 29.2%, 6.2%, and 6.2%, respectively. No resistance to nitrofurantoin was observed, and only two strains were resistant to carbapenems. ESBL-producing strains demonstrated significantly higher resistance rates to most clinically relevant antimicrobials compared to non-producing strains. Among cephalosporins, resistance rates exceeded 90% for cefazolin, cefuroxime, and ceftriaxone, followed by cefepime (65.3%) and ceftazidime (29.3%). Notably, resistance to ampicillin-sulbactam was 50.7%, with greater sensitivity observed for cefoperazone-sulbactam and piperacillin-tazobactam. Resistance to cefotetan and nitrofurantoin remained low, and no carbapenem-resistant ESBL-producing strains were identified. Multifactorial logistic regression analysis indicated that abnormal urinary tract structure and a history of antibiotic treatment within the past 3 months were independent risk factors for UTIs caused by ESBL-producing E. coli (OR = 2.323, 95% CI = 1.052-5.129, P = 0.037 and OR = 3.378, 95% CI = 1.116-10.224, P = 0.031, respectively). CONCLUSIONS: ESBL-producing E. coli infections in pediatric UTIs are very common in our hospital, with high resistance rates to many used antibiotics. Awareness of the risk factors-namely, abnormal urinary tract structure and recent antibiotic treatment-is essential for effective management. Empirical treatment should involve a rational selection of antimicrobials based on local bacterial resistance patterns.