Oral Narrow-Spectrum Antibiotics for the Treatment of Urinary Tract Infection in Infants Younger Than 60 Days

Outcomes associated with initial narrow-spectrum versus broad-spectrum antibiotics in children hospitalized with urinary tract infections

OBJECTIVE

The aim of this study is to describe the proportion of children hospitalized with urinary tract infections (UTIs) who receive initial narrow- versus broad-spectrum antibiotics across children's hospitals and explore whether the use of initial narrow-spectrum antibiotics is associated with different outcomes.

DESIGN, SETTING AND PARTICIPANTS

We performed a retrospective cohort analysis of children aged 2 months to 17 years hospitalized with UTI (inclusive of pyelonephritis) using the Pediatric Health Information System (PHIS) database.

MAIN OUTCOME AND MEASURES

We analyzed the proportions of children initially receiving narrow- versus broad-spectrum antibiotics; additionally, we compiled antibiogram data for common uropathogenic organisms from participating hospitals to compare with the observed antibiotic susceptibility patterns. We examined the association of antibiotic type with adjusted outcomes including length of stay (LOS), costs, and 7- and 30-day emergency department (ED) revisits and hospital readmissions.

RESULTS

We identified 10,740 hospitalizations for UTI across 39 hospitals. Approximately 5% of encounters demonstrated initial narrow-spectrum antibiotics, with hospital-level narrow-spectrum use ranging from <1% to 25%. Approximately 80% of hospital antibiograms demonstrated >80% Escherichia coli susceptibility to cefazolin. In adjusted models, those who received initial narrow-spectrum antibiotics had shorter LOS (narrow-spectrum: 33.1 (95% confidence interval [CI]: 30.8-35.4) h versus broad-spectrum: 46.1 (95% CI: 44.1-48.2) h) and reduced costs [narrow-spectrum: $4570 ($3751-5568) versus broad-spectrum: $5699 ($5005-$6491)]. There were no differences in ED revisits or hospital readmissions. In summary, children's hospitals have low rates of narrow-spectrum antibiotic use for UTIs despite many reporting high rates of cefazolin-susceptible E. coli. These findings, coupled with the observed decreased LOS and costs among those receiving narrow-spectrum antibiotics, highlight potential antibiotic stewardship opportunities.

URINARY TRACT INFECTIONS IN PATIENTS YOUNGER THAN 60 DAYS OLD

The safety and efficacy of transitioning from parenteral to oral antibiotics in patients aged less than 60 days with urinary tract infections were assessed. Patients who transitioned to oral therapy had a lower mean length of stay with no significant difference in medically attended urinary tract infection symptoms within 30 days of treatment.

Short-course intravenous antibiotics for young infants with urinary tract infection

OBJECTIVE

Shorter courses of intravenous antibiotics for young infants with urinary tract infection (UTI) have myriad advantages. As practice shifts toward shorter intravenous treatment courses, this study aimed to determine the safety of early intravenous-to-oral antibiotic switch and identify risk factors for bacteraemia with UTI.

METHODS

Retrospective audit of infants aged ≤90 days with a positive urine culture at a quaternary paediatric hospital over 4 years (2016-2020). Data were collected from the hospital electronic medical record and laboratory information system. Short-course intravenous antibiotic duration was defined as <48 hours for non-bacteraemic UTI and <7 days for bacteraemic UTI. Multivariate analysis was used to determine patient factors predicting bacteraemia.

RESULTS

Among 427 infants with non-bacteraemic UTI, 257 (60.2%) were treated for <48 hours. Clinicians prescribed shorter intravenous courses to infants who were female, aged >30 days, afebrile and those without bacteraemia or cerebrospinal fluid pleocytosis. Treatment failure (30-day UTI recurrence) occurred in 6/451 (1.3%) infants. All had non-bacteraemic UTI and one received <48 hours of intravenous antibiotics. None had serious complications (bacteraemia, meningitis, death). Follow-up audiology occurred in 21/31 (68%) infants with cerebrospinal fluid pleocytosis, and one had sensorineural hearing loss. Bacteraemia occurred in 24/451 (5.3%) infants, with 10 receiving <7 days intravenous antibiotics with no treatment failure. Fever and pyelonephritis were independent predictors of bacteraemia.

CONCLUSION

Short-course intravenous antibiotics for <48 hours for young infants with non-bacteraemic UTI should be considered, provided meningitis has been excluded. Treatment failure and serious complications were rare in young infants with UTI.

Short Intravenous Antibiotic Courses for Urinary Infections in Young Infants: A Systematic Review

CONTEXT

Urinary tract infections (UTIs) are common in young infants, yet there is no guidance on the optimal duration of intravenous (IV) treatment.

OBJECTIVE

To determine if shorter IV antibiotic courses (≤7 days) are appropriate for managing UTIs in infants aged ≤90 days.

METHODS

PubMed, the Cochrane Library, Medline, and Embase (February 2021) were used as data sources. Included studies reported original data for infants aged ≤90 days with UTIs, studied short IV antibiotic durations (≤7 days), and described at least 1 treatment outcome. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline was followed. Studies were screened by 2 investigators, and bias was assessed by using the Newcastle-Ottawa Scale and the Revised Cochrane Risk-of-Bias Tool.

RESULTS

Eighteen studies with 16 615 young infants were included. The largest 2 studies on bacteremic UTI found no difference in the rates of 30-day recurrence between those treated with ≤7 vs >7 days of IV antibiotics. For nonbacteremic UTI, there was no significant difference in the adjusted 30-day recurrence between those receiving ≤3 vs >3 days of IV antibiotics in the largest 2 studies identified. Three studies of infants aged ≥30 days used oral antibiotics alone and reported good outcomes, although only 85 infants were ≤90 days old.

CONCLUSIONS

Shorter IV antibiotic courses of ≤7 days and ≤3 days with early switch to oral antibiotics should be considered in infants aged ≤90 days with bacteremic and nonbacteremic UTI, respectively, after excluding meningitis. Further studies of treatment with oral antibiotics alone are needed in this age group.

Treatment of UTIs in Infants <2 Months: A Living Systematic Review

CONTEXT

Urinary tract infections (UTIs) are the most common bacterial infections in infants <2 months of age. However, there are no clear guidelines on the appropriate duration of antibiotics in this age group.

OBJECTIVE

In this living systematic review, we compared different durations of parenteral antibiotics (≤3 vs >3 days) in neonates and young infants (<2 months) with UTIs. The secondary objective was to compare different durations of total antibiotic courses (≤10 vs >10 days).

DATA SOURCES

MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Web of Science, Literatura Latino-Americana e do Caribe em Ciências da Saúde, Google Scholar, and gray literature, up to March 2, 2021.

STUDY SELECTION

Citations were screened in triplicate by using a crowdsourcing methodology, to identify randomized controlled trials and observational studies.

DATA EXTRACTION

Data were extracted by 2 crowd members and verified by an expert investigator. Outcomes were pooled via random-effects models.

RESULTS

A total of 10 334 citations were screened, and 12 eligible studies were identified. A total of 59 of 3480 (1.7% [95% confidence interval (CI): 1.3% to 2.2%]) infants had a UTI recurrence within 30 days after short parenteral treatment (≤3 days), and 47 of 1971 (2.4% [95% CI: 1.8% to 3.2%]) after longer courses. The pooled adjusted odds ratio for UTI recurrence with a short versus long duration of parenteral antibiotics was 1.02 (95% CI: 0.64 to 1.61; P = .95; n = 5451). A total of 5 studies assessed the risk of recurrence on the basis of the total duration of antibiotics (≤10 vs >10 days) with no significant differences (pooled odds ratio: 1.29 [95% CI: 0.45 to 3.66; P = .63; n = 491).

CONCLUSIONS

On the basis of retrospective studies and Grading of Recommendations, Assessment, Development, and Evaluation level low evidence, short and long duration of parenteral antibiotics were associated with a similar risk of UTI recurrence in infants <2 months.