Short Parenteral Courses for Young Infants With UTI

Urinary tract infections (UTIs) occur in ∼7% of febrile infants in the first 2 months of life.¹ The American Academy of Pediatrics clinical practice guideline for the management of UTIs includes infants between 2 and 24 months of age, but does not provide guidance for infants <2 months.² This has resulted in significant variability in duration of parenteral therapy in young infants with UTIs, although the factors that drive this variation are less clear.³

In this issue of Hospital Pediatrics, authors of two retrospective studies evaluate patterns in parenteral therapy use for UTI treatment in infants during the first 2 months of life. Marsh et al⁴ studied 112 infants ≤28 days of age hospitalized for UTI without bacteremia at 2 academic centers. The median duration of parenteral therapy was 49 hours, with duration >48 hours associated with age <7 days, genitourinary anomalies, having a secondary diagnosis extending hospitalization, and subspecialty consultation. Swartz et al⁵ studied 193 infants ≤60 days of age hospitalized for UTI with or without bacteremia at a single children’s hospital. The median duration of parenteral therapy was 59 hours (median of 88 hours in infants ≤28 days and 54 hours in infants 29–60 days old). Longer parenteral therapy was associated with younger age, fever for 24 hours or more, bacteremia, and initial irritability or lethargy.

In these 2 studies, the authors provide a closer look at practice patterns for UTI management at 3 institutions and contribute to the growing literature revealing a shift toward shorter durations of parenteral antibiotics in an age group for which national consensus guidelines are lacking. Furthermore, although these studies were not powered to detect differences in treatment failure rates by parenteral therapy duration, it is reassuring that the overall treatment failure rates were low (0.9% in the study by Marsh et al⁴ and 2.6% in the study by Swartz et al⁵) and consistent with larger studies.^3,6,7 For providers seeking to transition young infants earlier to oral therapy rather than treat with a predetermined parenteral duration, these findings provide examples of this practice with detailed clinical context. Shorter durations of parenteral antibiotics lessen the need for central lines and avoid their potential complications, reduce exposure to nosocomial infections, and curtail hospital days and their associated costs. Additionally, reduced lengths of stay in young infants enable the mother-infant dyad to spend more time at home during a critical period of breastfeeding and bonding, both of which are potentially disrupted in a hospital environment.⁸

These studies’ findings suggest several important areas for future research. First, it is unclear what the optimal duration of parenteral therapy is for young infants with UTI. Even with a trend toward shorter courses, there is significant institutional variability, and some providers and institutions manage well-appearing infants 29 to 60 days of age as outpatients.⁹ The ideal study design would be a randomized control trial of various approaches, powered to identify clinically meaningful differences in incidence of treatment failure. However, such a study may be difficult to conduct because institutional momentum is shifting toward shorter courses. A more practical approach includes continued evaluation through multisite comparative effectiveness studies with detailed clinical data, which are key in evaluating differences in outcomes by parenteral therapy duration. Second, we do not know if there is a subset of young infants who are at higher risk of treatment failure, and if they might benefit from longer parenteral courses. Finally, as more data reveal the safety and effectiveness of short parenteral courses, multicenter studies on drivers of parenteral duration would help us understand the generalizability of these findings and identify potential targets for quality improvement efforts.

The durations of parenteral antibiotics for common pediatric infections have been appropriately scrutinized in the recent decades in efforts to focus on high-value care that adequately balances benefits and potential harms. Here, we see that institutions are chiseling away at the tenet of longer duration parenteral antibiotic therapy in young infants with UTI. As this practice pattern continues to shift, large-scale studies will be important to continually assess its impact on clinical outcomes.

• Copyright © 2020 by the American Academy of Pediatrics