Outpatient Treatment of UTIs in the Young Child: The Time Has Come

ABSTRACT & COMMENTARY

Source: Hoberman A, et al. Oral versus initial intravenous therapy for urinary tract infections in young febrile children. Pediatrics 199;104:79-86.

Is it safe and effective to treat febrile young children with urinary tract infections (UTIs) as outpatients with oral antibiotics? Hoberman and colleagues provide us with very useful data in answer to this clinical question. In a study involving four pediatric EDs, 306 children ages 1-24 months with fever and UTI were randomized to be treated with oral cefixime for 14 days (double dose on day 1), or intravenous (IV) cefotaxime for three days and then oral cefixime to complete a 14-day course of therapy. The short-term outcomes studied were sterilization of the urine at ~24 hours and time to defervescence; the long-term outcomes studied were incidence of reinfection and incidence and extent of renal scaring documented at six months by DMSA scan. Children between 4 and 8 weeks of age who were randomized to the oral therapy treatment arm (n = 4) were admitted to the hospital on oral therapy, observed, and discharged when afebrile to complete the 14-day course of therapy. Also, children randomized to the oral treatment arm who had vomiting that interfered with oral therapy were observed and given a trial of oral or IV fluids along with the trial dose of cefixime. Only one child randomized to the oral arm was ultimately excluded from the trial because of refractory emesis.

The treatment groups were comparable in all relevant aspects, including coexistent bacteremia rates (3.4% in oral group and 5.3% in IV group) and prevalence of pyelonephritis (65% in the oral group and 57% in the IV group). As you would expect, Escherichia coli was the causative pathogen in 97% of the infections. Short-term outcomes: 1) all of the children had negative repeat urine cultures (and blood cultures) at ~24 hours; and 2) mean time to defervescence was similar between the two groups. Long-term outcomes: 1) the incidence of reinfection was similar between the groups (4.6% in the oral groups and 7.2% in the IV group); and 2) renal scaring at 6 months was present in 9.8% of children treated orally and 7.2% in children treated IV (P = 0.21), and the extent of renal scaring was 8% in both groups.

Comment by Leonard Friedland, MD

These data clearly support the decision to treat most young febrile children with a suspected UTI (and pyelonephritis) as outpatients with oral antibiotics. I state most, as this choice is not appropriate for the toxic appearing child, the infant younger than 8 weeks of age with whom bacteremia and increased risk for meningitis must also be a concern, and the child with vomiting that prevents oral therapy. These data also show that children admitted for a short course of IV therapy followed by oral therapy have good short-term and long-term outcomes. Another finding suggests that obtaining blood cultures in febrile young children with UTI is not necessary, as the yield is low and all repeat cultures were sterile after 24 hours of UTI therapy. When considering empiric therapy, the initial choice of a third-generation cephalosporin such as cefixime is a "big gun," and once identification and sensitivities are known, the antibiotic selection should be narrowed. The incidence of renal scaring was fortunately low in these patients and likely secondary to vigilance in looking for a UTI as the source in a febrile infant, early antibiotic therapy, and close follow-up.

In young febrile children with a UTI, all of the following are correct except:

a. therapy with oral antibiotics is not as effective as IV therapy.

b. E. coli is the most common causative pathogen.

c. a history of emesis does not preclude oral antibiotic therapy.

d. pyelonephritis is present in more than one-half of these cases.