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Managing UTI in young children: Learn whats new
Oral antibiotics can be used, and researchers continue to look for better ways to determine reflux.
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NEW YORK — An expert in urinary tract infections (UTIs) said that his group now manages UTIs with oral antibiotics, instead of IV antibiotics.
“We have shifted over to using oral antibiotics in the management of UTI, and very rarely do we use IV antibiotics now in treating young children with UTI,” said Alejandro Hoberman, MD, at the 17th Annual Infectious Diseases in Children Symposium here.
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“If children look extremely sick, some folks have decided to use ceftriaxone in the emergency room and follow with oral antibiotic. That’s fine, too. Probably the way of thinking about it is how my colleague, Robert Hickey, has always told me: ‘The bugs don’t care how the antibiotics get to them,’” said Hoberman, who is a member of the Infectious Diseases in Children editorial advisory board.
Oral vs. IV
In a multicenter randomized clinical trial, Hoberman and his colleagues compared the effectiveness of oral vs. IV antimicrobial therapy in febrile children aged 1 to 24 months. Patients were enrolled from Children’s Hospital of Pittsburgh, Columbus Children’s Hospital in Ohio, Children’s Hospital in Boston and Inova Children’s Hospital in Fairfax, Va. Children were eligible if they had a temperature greater than 38.3ºC within 24 hours, pyuria on the enhanced urinalysis (UA) with 10 white cells/mm3 and bacteriuria as defined as any gram-negative rod per 10 oil immersion fields.
The children entered the trial when they presented to the emergency department prior to knowing the culture results. A positive culture was required within 24 to 48 hours to remain in the trial; positivity was defined as the growth of at least 50,000 colony-forming units/mL of a single pathogen on a catheterized urine specimen.
“Children were ... randomized to receive oral antibiotics administered as 14 days of oral cefixime [Suprax, Lupin]. The first day we used a double dose at 16 mg/kg or IV antibiotics, which was inpatient, and it was three days of IV cefotaxime followed by 11 days of oral cefixime.
Inpatients were seen every day; outpatients were brought back at 24, 48 and 72 hours for follow-up. A dimercaptosuccinic acid (DMSA) renal scan and a renal ultrasound were conducted within 48 hours.
Follow-up for all children was done at 14 days. In addition, someone called each month. If children developed fever at any point, they were told to see their pediatrician to get a urine specimen.
“Prophylactic antimicrobials in those days were administered for two weeks until the voiding cystourethrogram [VCUG] was done, which was conducted at four to six weeks after the initial diagnosis, and a follow-up urine culture was done at 24 hours and again at three and six months. A repeat DMSA scan was done at six months to identify the presence of renal scarring, which constituted the main outcome of the study,” Hoberman said.
Short-term outcomes included sterilization of the urine within 24 hours and time to defervescence. Long-term outcomes were the incidence and extent of renal scarring as determined by the DMSA renal scan and the likelihood of reinfection within six months.
There was follow-up information on 90% of the 309 children. The demographics of the two groups were similar. “It’s a disease of children mostly under 1 year old, 70-some percent under 1 year old; mostly girls, 90% girls; and mostly white, 75% white,” said Hoberman.
“In our study, about 60% of children in each of the two treatment groups had acute pyelonephritis diagnosed by DMSA renal scans within 48 hours of diagnosis,” he said.
The findings of renal ultrasonography were normal in about 90% of children. Abnormalities identified were a dilated pelvis, pelvic caliectasis, hydronephrosis, dilated ureter, double collecting systems, extra pelvis and calculus, but they did not alter the management of any child, he said.
Approximately 40% of children had vesicoureteral reflux, most of them grades 1, 2 and 3. Only 5% of children had grade 4. None had grade 5.
Abnormal ultrasonograms were more likely to happen in those with high-grade reflux, according to Hoberman.
“Even though high-grade reflux is more likely to be seen in children with an abnormal ultrasound, it also happened among children with normal ultrasounds that show no evidence of dilatation of the urinary tract,” he said.
Younger children in the study were not more likely to have renal scarring than their older counterparts, he added. But that could have been because physicians tend to be more aggressive in screening for UTI in infants younger than 12 months and a shorter duration of fever before initiating antibiotic treatment may decrease the likelihood of renal scarring.
A sterile urine culture was documented within 24 hours in 100% of children. Defervescence occurred within 24 hours in both treatment groups.
No difference was apparent in the likelihood of reinfection or renal scarring between treatment groups.
“If we focus on the group of children who had acute pyelonephritis, and accordingly are the only ones at risk for renal scarring, scarring occurred in 16.9% and 13.6% in the oral and intravenous group, respectively, but the extent of scarring was relatively small: 8% of the kidney parenchyma was affected,” Hoberman said.
Factors affecting renal scarring, vesicoureteral reflux
A host of inflammatory-reaction and pathogen-specific factors, as well as gender-specific differences, affect scaring, he said.
Girls tend to get the focal renal scars following recurrent UTIs, while boys get the global parenchymal loss with dilated reflux, in general.
Most children with UTI generally have good prognosis, and there is a relatively low risk of renal dysfunction and hypertension, according to Hoberman.
When vesicoureteral reflux is present, it is usually of low grade, and initiatives are being undertaken at the NIH to support studies that will evaluate the need for long-term prophylactic antimicrobials in these children, he added. More universal prenatal ultrasounds being done and enhanced technology of prenatal ultrasounds, together with enhanced technology, permits early identification of children with obstructions of the urinary tract that are then placed on prophylactic antibiotics, preventing UTIs.
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“So, we may end up with less invasive and more evidence-based imaging for UTI in children. However, it’s hard to change management of children with vesicoureteral reflux until this evidence is gathered,” Hoberman said.
“If a child has a fever and pyuria on the enhanced UA, we don’t do a blood culture anymore , because we know the likelihood of bacteremia is low and has not modified management. We obtain a renal ultrasound in children with a delayed response to treatment and in those who have not had a prenatal ultrasound after approximately 30 weeks of pregnancy at a reputable university.
“We will continue to perform the VCUG to identify children with reflux until the question of whether prophylactic antibiotics prevent renal scarring is answered. However, we do not routinely obtain DMSA scans at the time of infection and six months later. We prefer an approach of routine screening for subsequent febrile illnesses in children with UTI that may obviate the need for some other these tests.”
He added that outpatient treatment is safe and effective in young children with fever and UTI. – by Marie Rosenthal
For more information:
- Hoberman A. Urinary tract infection in young children: controversies in management and imaging. Presented at the 17th Annual Infectious Diseases in Children Symposium. Nov. 20-21, 2004. New York.