Article: Hikmat S, Lawrence J, Gwee A. Short Intravenous Antibiotic Courses for Urinary Infections in Young Infants: A Systematic Review. Pediatrics. 2022;149(2):e2021052466. doi:10.1542/peds.2021-052466
Fellow: Purva Patel, MD; Baylor College of Medicine/Texas Children’s Hospital
Summary: There is lack of guidance regarding the duration of intravenous (IV) antibiotic duration of urinary tract infections (UTI) in infants </=90 days. This systematic review aimed to determine if shorter IV antibiotic courses (</=7 days) are appropriate for managing UTIs in infants </=90 days old. Included studies reported on infants </=90 days old with UTIs with and/or without bacteremia; treatment with short IV antibiotic duration (</=7 days) or oral therapy; and described at least 1 treatment outcome. Overall, 18 studies (2 RCT, 16 observational) and 16,615 infants were included. Initial treatment with IV antibiotics were used for treatment of all infants in 15 of the 18 studies, and 3 studies included oral antibiotic treatment in some or all of the infants ages 1-3 months old. Most studies excluded infants with meningitis in their study population. Among infants <90 days old with bacteremic UTI (N = 468) and without bacteremic UTIs (N = 15826), UTI recurrence rates were low and short IV antibiotic duration (</=7 days for bacteremic UTIs, </=3 days for nonbacteremic UTIs) was not associated with increased rates of 30-day UTI recurrence. Majority of the UTI recurrences occurred in infants with renal tract abnormalities, particularly vesicoureteral reflux.
Key Strengths: This systematic review had a large sample size and focused on the specific population of infants </=90 days old with UTIs to address the evidence of optimal timing of IV to oral antibiotic switch. Previous systematic reviews addressing this clinical question in children with UTIs have not focused on this specific age group.
Limitations/Flaws: There is the potential for the underestimation of UTI recurrence rates because none of the studies accounted for infants with recurrence that presented to other healthcare centers. Moreover, other complications such renal scarring was not investigated in many of the included studies which could also result in underestimation of long-term complications. Majority of the studies included were observational studies limiting the quality of evidence. The 2 RCTs included described outcomes in infants with UTIs treated with oral cefixime alone versus IV cephalosporin followed by oral cefixime, but overall had a small sample size of infants 1-3 months old and further research is needed in this age group.
Takeaway Message: In infants </=90 days old with UTIs and meningitis excluded, there was no difference in the rates of UTI recurrence between short (</=7 days for bacteremic, </=3 for nonbacteremic) and long IV antibiotic duration. Because many infants who experienced recurrence were found to have a renal anomalies, recurrence in this population is likely due to underlying abnormality rather than route and duration of antibiotic treatment.
Practice Impact: The results of this study suggest that it is reasonable to consider earlier switch to oral antibiotics in young infants with UTIs with or without bacteremia. Shorter IV antibiotic courses and earlier switch to oral antibiotics can reduce length of hospital stays, health care costs, and the risk of nosocomial infections resulting in improved quality of life for infants and their families.
Fellow: Purva Patel, MD; Baylor College of Medicine/Texas Children’s Hospital
Summary: There is lack of guidance regarding the duration of intravenous (IV) antibiotic duration of urinary tract infections (UTI) in infants </=90 days. This systematic review aimed to determine if shorter IV antibiotic courses (</=7 days) are appropriate for managing UTIs in infants </=90 days old. Included studies reported on infants </=90 days old with UTIs with and/or without bacteremia; treatment with short IV antibiotic duration (</=7 days) or oral therapy; and described at least 1 treatment outcome. Overall, 18 studies (2 RCT, 16 observational) and 16,615 infants were included. Initial treatment with IV antibiotics were used for treatment of all infants in 15 of the 18 studies, and 3 studies included oral antibiotic treatment in some or all of the infants ages 1-3 months old. Most studies excluded infants with meningitis in their study population. Among infants <90 days old with bacteremic UTI (N = 468) and without bacteremic UTIs (N = 15826), UTI recurrence rates were low and short IV antibiotic duration (</=7 days for bacteremic UTIs, </=3 days for nonbacteremic UTIs) was not associated with increased rates of 30-day UTI recurrence. Majority of the UTI recurrences occurred in infants with renal tract abnormalities, particularly vesicoureteral reflux.
Key Strengths: This systematic review had a large sample size and focused on the specific population of infants </=90 days old with UTIs to address the evidence of optimal timing of IV to oral antibiotic switch. Previous systematic reviews addressing this clinical question in children with UTIs have not focused on this specific age group.
Limitations/Flaws: There is the potential for the underestimation of UTI recurrence rates because none of the studies accounted for infants with recurrence that presented to other healthcare centers. Moreover, other complications such renal scarring was not investigated in many of the included studies which could also result in underestimation of long-term complications. Majority of the studies included were observational studies limiting the quality of evidence. The 2 RCTs included described outcomes in infants with UTIs treated with oral cefixime alone versus IV cephalosporin followed by oral cefixime, but overall had a small sample size of infants 1-3 months old and further research is needed in this age group.
Takeaway Message: In infants </=90 days old with UTIs and meningitis excluded, there was no difference in the rates of UTI recurrence between short (</=7 days for bacteremic, </=3 for nonbacteremic) and long IV antibiotic duration. Because many infants who experienced recurrence were found to have a renal anomalies, recurrence in this population is likely due to underlying abnormality rather than route and duration of antibiotic treatment.
Practice Impact: The results of this study suggest that it is reasonable to consider earlier switch to oral antibiotics in young infants with UTIs with or without bacteremia. Shorter IV antibiotic courses and earlier switch to oral antibiotics can reduce length of hospital stays, health care costs, and the risk of nosocomial infections resulting in improved quality of life for infants and their families.