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Shorter IV antibiotic courses likely effective for many urinary tract infections in infants

Reuters Health - 09/02/2022 - Shorter intravenous (IV) antibiotic courses, with an early switch to oral antibiotics, can be considered for infants ages 90 days or less with bacteremic or nonbacteremic urinary tract infection (UTI), a systematic review suggests.

"We found that for bacteremic UTI, seven days or less of IV treatment is appropriate, while for nonbacteremic UTI, three days or less would be sufficient," Dr. Amanda Gwee of the University of Melbourne, Victoria told Reuters Health by email. "These shorter IV courses were not associated with an increased risk of getting a further UTI, requiring hospitalization, or needing admission to an intensive care unit."

Importantly, she added, "These findings only apply to babies who are not septic and those in whom meningitis has been excluded."

"For babies aged between 30 and 90 days, three studies reported good outcomes with oral antibiotic treatment alone," she noted. "But these studies only included 85 babies and this needs further study."

As reported in Pediatrics, a literature search through February 2021 resulted in 18 studies involving more than 16,000 infants ages 90 days or less.

The two largest studies on bacteremic UTI found no difference in the rates of 30-day recurrence between those treated with IV antibiotics for 7 days or less versus >7 days.

Similarly, for nonbacteremic UTI, 12 studies included more than 15,000 infants. In the two largest studies, no significant difference was seen in the adjusted 30-day recurrence between those receiving IV antibiotics for 3 days or less versus >3 days.

As Dr. Gwee noted, three studies of infants aged 30 days or older used oral antibiotics alone and reported good outcomes, although only 85 infants were 90 days old or younger.

"Most of the studies included in our review were observational and retrospective studies which have limitations," she said. "Therefore, we want to study this prospectively, particularly focusing on whether we can use oral antibiotics alone for UTI once the bacteremia has cleared."

Nonetheless, she added, "We hope that our systematic review will inform a consensus guideline so that we can standardize care for babies with UTI."

Dr. Brenda Anosike, a pediatric infectious disease specialist at the Children's Hospital at Montefiore in New York City, called the study "quite promising."

However, like Dr. Gwee, she noted that the study was observational and therefore "prone to bias and confounding."

"In addition," she said, "there is limited information on use of antibiotics prior to admission or those who were on prophylactic antibiotics; this would impact UTI diagnosis and whether the UTI represents a first or recurrent episode."

"While there is growing interest in improving antimicrobial stewardship with positive downstream effects - i.e., less antibiotics and thus less potential for adverse effects, reduced need for central line placement, less exposure to nosocomial infections, reduced hospital length of stay - we are often challenged by a non-negligible number of cases where meningitis can NOT always be excluded conclusively." In such cases, "antibiotics are often empirically started to avoid delays in therapy."

Further, she said, "There is a subset of patients who have sterile CSF pleocytosis - i.e., the CSF findings may suggest meningitis, but the infecting pathogen does not grow on CSF culture. In such cases, most would treat as a meningitis necessitating IV therapy for the entire duration of treatment, for a minimum of 14 days for some."

SOURCE: https://bit.ly/3HHn3cu Pediatrics, online January 25, 2022.

By Marilynn Larkin

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