A Comparison of Short Versus Long Term Intravenous Antibiotics When Treating Urinary Tract Infection in Infants <60 days
Fadi Zu'bi, MD1, Martha Pokarowski, MPH1, Rusul Al-Kutbi, MD1, Michelle Science, MD2, Janaki Vallipuram, MD3, Fardod O'Kelly, MD1, Jeremy Freidman, MD3, Martin A. Koyle, M.D., MSc, FAAP, FACS, FRCS (Eng.), FRCSC1.
1Division of Urology, The Hospital For Sick Children, Toronto, ON, Canada, 2Division of Infectious Diseases, The Hospital For Sick Children, Toronto, ON, Canada, 3Division of Pediatric Medicine, The Hospital For Sick Children, Toronto, ON, Canada.
Background
Urinary tract infections (UTIs) are a common reason for hospitalization in young infants, with more than 20,000 infants (< 1 year) hospitalized each year in the United States. In children 2 to 24 months of age, the American Academy of Pediatrics guidelines from 2011 (reaffirmed in 2016) state that "initiating treatment orally or parenterally is equally efficacious". Infants less than 60 days old often initially receive parenteral antibiotics as part of an evaluation for invasive bacterial infection. The optimal approach to intravenous (IV) antibiotic therapy when a UTI is diagnosed in these younger infants is not known. As a result, significant practice heterogeneity exists even within institutions. The goal of this study was to determine the association between short term ( 3days) and long term (3days) IV antibiotic therapy and treatment failure, defined as readmission within 30 days. We hypothesized that a short course IV antibiotic therapy followed by oral antibiotics is safe, with no difference in treatment failure between short and long term IV antibiotic therapy.
Methods
We retrospectively reviewed the medical records of all infants < 60 days old with confirmed bacterial UTI's who were admitted and received IV antibiotics between January 1, 2008 and December 31, 2017. We excluded any catheter-associated UTI, prior urological procedures, mixed growth urine cultures, fungal growth and bacterial meningitis. The primary outcome was readmission within 30 days for a UTI. Data were summarized as median (IQR), counts and percentages. For comparison of each group, Chi-square and Fischer's exact tests were used for categorical variables and Mann Whitney U test for non-parametric continuous data. We also performed univariate analysis and multivariate logistic regression for the significant variables noted on univariate analysis (p-value<0.05).
Results
During the study period, 403 infants were included. Characteristics of the study population are summarized in table 1. The median age was 21 days (IQR=8-39) and 295 infants (74%) were boys. 155 (39%) were treated with Ampicillin and Cefotaxime and 135 (34%) with Ampicillin and Gentamycin/Tobramycin. The median IV antibiotic duration was 5 days (IQR= 3-10). Oral Cephalexin was used in the continuation phase in 48% and the total period of treatment (oral and IV) was 10 days (IQR=9-14).
19/403 (5%) experienced treatment failure. The treatment failure rate was similar (5%) in the two groups (p= 0.95). After multivariate adjustment, there was no significant association between treatment group and treatment failure, with an odds ratio for long versus short treatment of 0.5 (95% confidence interval:0.19-1.27). Prematurity, recurrent UTI, sex, hospital acquired UTI, positive blood cultures and the presence of comorbidities were not predictive of treatment failure.
Conclusions
Treatment failure for infants hospitalized in the first 2 months of life with UTI is uncommon and is not associated with duration of IV antibiotic treatment. Treating more infants of this age group with short courses of IV antibiotic therapy might decrease resource use without affecting readmission rates.
| Total | IV Duration | P | ||
| N (%) | Short Term (<3 days) N(%) | Long Term (>3 days) N (%) | ||
| No. of patients, n (%) | 403 | 167 (41) | 236 (59) | - |
| Premature CGA | <0.001 | |||
| Yes | 77 (20) | 5 (3) | 72 (32) | |
| No | 311 (80) | 158 (97) | 153 (68) | |
| Comorbidities | <0.001 | |||
| Yes | 149 (38) | 19 (12) | 130 (57) | |
| No | 246 (62) | 146 (88) | 100 (43) | |
| Hospital acquired infection | <0.001 | |||
| Yes | 104 (26) | 8 (5) | 96 (41) | |
| No | 297 (74) | 159 (95) | 138 (59) | |
| UTI history | 0.109 | |||
| First | 368 (92) | 157 (95) | 211 (90) | |
| Recurrent | 32 (8) | 9 (5) | 23 (10) | |
| Urine culture | <0.001 | |||
| E. Coli | 242 (60) | 133 (80) | 109 (46) | |
| Klebsiella | 33 (8) | 8 (5) | 25 (11) | |
| Pseudomonas | 7 (2) | 2 (1) | 5 (2) | |
| Staphylococcus A | 10 (2) | 3 (2) | 7 (3) | |
| Enterobacter | 33 (8) | 4 (2) | 29 (12) | |
| Enterococcus | 51 (13) | 13 (8) | 38 (16) | |
| Other | 27 (7) | 4 (2) | 23 (10) | |
| Blood culture | <0.001 | |||
| Positive | 59 (15) | 4 (2) | 54 (23) | |
| Negative | 342 (85) | 162 (98) | 181 (77) | |
| Lumbarpuncture performed | 0.836 | |||
| Yes | 240 (60) | 98 (59) | 142 (60) | |
| No | 160 (40) | 67 (41) | 93 (40) | |
| Total treatment of period (days) | <0.001 | |||
| Median (IQR) | 10 (9-14) | 10 (9-12) | 12 (9-14) | |
| Oral antibiotic duration (days) | 0.3004 | |||
| Median (IQR) | 8 (7-10) | 8 (7-10) | 6 (5.5-10) | |
| KUB Ultrasound performed | 0.094 | |||
| Yes | 351 (87) | 151 (90) | 200 (85) | |
| No | 52 (13) | 16 (10) | 36 (15) | |
| Abnormal KUBUS findings | 0.188 | |||
| Yes | 139 (40) | 54 (36) | 85 (43) | |
| No | 211 (60) | 97 (64) | 114 (57) | |
| VUR on VCUG | 0.932 | |||
| Yes | 68 (35) | 24 (36) | 44 (35) | |
| No | 124 (65) | 43 (64) | 81 (65) | |
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