Antimicrobial Therapy for Lower Urinary Tract Infections in Children

Abstract & Commentary

Synopsis: A meta-analysis of 22 studies showed significant differences between cure rates for short and conventional (5 days or longer) courses of antimicrobial therapy for uncomplicated lower urinary tract infections in children, although 3 days of trimethoprim-sulfamethoxazole therapy appears to be as effective as conventional length courses of this drug.

Source: Tran D, et al. Short-course versus conventional length antimicrobial therapy for uncomplicated lower urinary tract infections in children: A meta-analysis of 1279 patients. J Pediatr. 2001;139:93-99.

A literature review of antimicrobial therapy for urinary tract infections in children yielded 517 citations. A meta-analysis was performed on 22 published trials that were selected by protocol, with a total of 1279 patients. Each study compared short-course and conventional course (5 days or longer) treatment using a single drug. All of the studies attempted to exclude children with pyelonephritis, as indicated by clinical signs, or elevated ESR or C-reactive protein. For all 22 studies, the test for heterogeneity was significant (P = .01), indicating that the differences among the studies in agents used and the definition of "short-course" therapy was significant. The overall difference in cure rates between single-dose/short-course and conventional length therapy was significant, favoring longer treatment (6.38%; 95% CI, 1.9-10.9%). Analysis of the 5 studies using amoxicillin showed that the test for heterogeneity was not significant (P = .6). The difference in cure rate for conventional length amoxicillin therapy was significantly better than for shorter courses (13.0%; 95% CI, 4.0- 24.0%). Analysis of the 6 studies using trimethoprim-sulfamethoxazole showed that the test for heterogeneity was significant (P = .004). The difference in cure rate between conventional and shorter courses of trimethoprim-sulfamethoxazole was not significant (6.2%; 95% CI, -3.7-16.2%).

Comment by Hal B. Jenson, MD, FAAP

Short-course antimicrobial therapy offers several potential advantages over conventional length of treatment, including increased compliance and potentially fewer adverse events. This meta-analysis demonstrated that among children with uncomplicated lower urinary tract infections, antimicrobial courses of 5 days or longer in duration were associated with higher cure rates. From the overall analysis, 16 patients (95% CI, 9- 53 patients) would have to receive conventional length therapy to prevent 1 treatment failure that would have occurred using single-dose or short-course therapy.

Analysis of the 5 studies using amoxicillin, 4 of which compared a single dose to conventional therapy, showed that the cure rate with shorter courses was significantly less than conventional length therapy. From this analysis, 8 patients (95% CI, 4-25 patients) would have to receive conventional length therapy to prevent 1 treatment failure that would have occurred using single-dose or short-course therapy. Similar analysis of the 6 studies that used trimethoprim-sulfamethoxazole, 3 of which compared a single dose to conventional therapy, showed no difference in cure rates between conventional and shorter courses. There were insufficient studies of other agents (eg, single-dose aminoglycosides, cephalo-sporins) for analysis.

Short-course therapy is less effective than courses of 5 or more days for treatment of uncomplicated lower urinary tract infections in children. This is largely the result of ineffectiveness of single-dose amoxicillin therapy. A 3-day course of trimethoprim-sulfamethoxazole appears to be as effective as longer courses of therapy.