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Ambulatory Treatment Feasible for Infants With Febrile Urinary Tract Infections

Posted Aug 10 2009 4:22pm
From Medscape Medical News

Laurie Barclay, MD
Charles P. Vega, MD, FAAFP

July 13, 2009 — Ambulatory treatment is feasible for infants aged 30 to 90 days with febrile urinary tract infections (UTIs), according to the results of a cohort study reported in the July issue of Pediatrics.

"It is common practice to hospitalize 1- to 3-month-old infants with febrile UTIs and to treat them with intravenously administered antibiotics," write Marie-Joëlle Doré-Bergeron, MD, from Sainte-Justine University Hospital Center, University of Montreal in Quebec, Canada, and colleagues. "This is the first study to examine ambulatory treatment with short-term, intravenous antibiotic therapy for young infants with febrile UTIs. This treatment option is feasible and may reduce significantly the number of hospital admissions for UTIs in this age group."

Between January 1, 2005, and September 30, 2007, a total of 118 children aged 30 to 90 days were seen for presumed febrile UTIs in the emergency department of a tertiary-care pediatric hospital and enrolled in this study. Of these, 67 (56.8%) were given intravenously administered antibiotics as outpatients in a day treatment center, and 51 (43.2%) met exclusion criteria and were hospitalized.

For those infants treated in the day treatment center, median age was 66 days (age range, 33 - 85 days), and the diagnosis of UTI was confirmed for 86.6% of patients. Urine culture results were positive for Escherichia coli in 84.5% of infants, and 98.3% of isolates were sensitive to gentamicin. Six infants (10.3%) had positive blood culture results, including 5 that were positive for E coli.

Mean duration of intravenous antibiotic treatment in the day treatment center was 2.7 days, and mean number of visits was 2.9, including appointments for voiding cystourethrography. The rate of parental compliance with day treatment center visits was 98.3%, and 8.6% of infants had problems with intravenous access. Of patients with confirmed UTIs, 86.2% underwent successful treatment in the day treatment center, defined as attendance at all visits, temperature normalization within 48 hours, negative control urine and blood culture results if cultures were performed, and no hospitalization from the day treatment center.

Limitations of this study include lack of generalizability to less intensively monitored care settings.

"Ambulatory treatment of infants 30 to 90 days of age with febrile urinary tract infections by using short-term, intravenous antibiotic therapy at a day treatment center is feasible," the study authors write. "Excellent parental compliance can be achieved in this setting, which allows close medical supervision. During the wait for more evidence on the safety of oral antibiotic therapy for very young infants with UTIs, this approach may reduce significantly the number of hospital admissions for UTI treatment in this age group."

The study authors have disclosed no relevant financial relationships.

Pediatrics. 2009;124:16-22.

Clinical Context

UTI can be a serious illness, particularly among young children, and the authors of the current study provide a review of the workup and management of UTIs. Bacteremia associated with UTI is most common among infants younger than 2 months, when the prevalence of bacteremia secondary to UTI may exceed 20%. However, there are few symptoms and signs to alert the clinician as to which child has bacteremia in the presence of a UTI. Thus, the standard of care calls for intravenous antibiotic therapy against gram-negative organisms for the initial treatment of UTIs among infants. Some research has found that oral antibiotic therapy is equally effective as parenteral therapy followed by oral treatment, but this result is not as well documented among infants.

The current study compares an outpatient-based treatment strategy for UTI vs inpatient treatment among infants between the ages of 1 to 3 months.
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