Background: There is an increasing prevalence of extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli-associated urinary tract infections (UTIs) in the pediatric population. These multidrug infections are challenging to treat. Objectives: Our aim is to study the clinical profile in children having urine culture positive with ESBL E. coli, antibiotic sensitivity pattern for ESBL E. coli in urine cultures, and evaluate clinical outcomes in patients with ESBL E. coli-associated UTI in our hospital. Methods: We collected reports of all urine cultures for age group 0–18 years with colony counts >10⁵ CFU/mL during the study period from January 2017 to December 2021 done in our hospital pathology lab. All urine culture positive reports were separated according to causative organism. From this, the subgroup of patients with ESBL E. coli was our study's focus. The prevalence of ESBL E. coli as a causative organism was calculated. These patients were further analyzed for clinical spectrum, antibiotic sensitivity pattern, and clinical outcome. Results: Out of 450 urine culture positive reports during the study period, E. coli was the most common organism with 259 (57%) cases. The maximum incidence of ESBL E. coli-associated urinary infection was in patients between 0 and 5 years (56%). The prevalence of infection in females (59%) was slightly higher than in males (41%). Extended-spectrum beta-lactamase E. coli are highly sensitive to the carbapenem group of antibiotics, amikacin, and fosfomycin. Resistance was 100% for ampicillin, aztreonam, ceftriaxone, and cefixime. Other antibiotics with high resistance were trimethoprim/sulfamethoxazole and the fluoroquinolone group of antibiotics. About 25% of children had h/o previous episodes of UTI. About 43% of patients had some significant underlying medical problem. About 51% of indoor patient department (IPD) patients had normal ultrasonogram (USG) or no findings related to the renal system. Each IPD patient was treated with antibiotics (IV plus oral) for 11 days on average. There were differences between in vitro antibiotic sensitivity and clinical experience for a few cephalosporin antibiotics. Overall mortality among IPD patients was 4%. Conclusions: Girls have more chances of getting UTIs due to ESBL E. coli than boys. Incidence of UTI due to ESBL E. coli is more during 0–5 years of life than in older children. Urinary tract infection due to ESBL E. coli is associated with high mortality. Carbapenems, amikacin, and fosfomycin are good choices of antibiotics to treat such infections. Antibiotic sensitivity patterns for cephalosporins derived by currently available methods do not always match clinical experience.