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Oral versus initial intravenous therapy for urinary tract infections in young febrile children
A Hoberman1, E R Wald, R W Hickey
1Department of Pediatrics, University of Pittsburgh School of Medicine and Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA. alejo+@pitt.edu
Insights
Oral cefixime offers a safe and effective outpatient treatment for febrile urinary tract infections in children, reducing costs and hospitalizations compared to intravenous therapy.
Area of Science:
- Pediatric Infectious Diseases
- Pharmacotherapy
- Clinical Trials
Background:
- Standard treatment for pediatric febrile urinary tract infections (UTIs) involves hospitalization and intravenous antimicrobials.
- Outpatient therapy with oral cephalosporins is being evaluated for safety, efficacy, and cost-effectiveness.
Purpose of the Study:
- To compare the efficacy and safety of oral versus initial intravenous antimicrobial therapy for febrile UTIs in children.
- To assess short-term clinical outcomes and long-term morbidity, including renal scarring.
Main Methods:
- A multicenter randomized clinical trial involving 306 children aged 1-24 months with febrile UTIs.
- Comparison of 14-day oral cefixime versus 3-day intravenous cefotaxime followed by 11-day oral cefixime.
- Evaluation of urine sterilization, defervescence, reinfection rates, and renal scarring at 6 months via 99mTc-dimercaptosuccinic acid scans.
Main Results:
- Both oral and intravenous therapies achieved urine sterilization and defervescence within 24-25 hours.
- Symptomatic reinfections occurred in 4.6% (oral) vs. 7.2% (intravenous).
- Renal scarring at 6 months was observed in 9.8% (oral) vs. 7.2% (intravenous), with similar mean scar extent (~8%).
- Mean healthcare costs were significantly lower for oral therapy ($1473) compared to intravenous therapy ($3577).
Conclusions:
- Oral cefixime is a safe and effective treatment option for children with febrile UTIs.
- Outpatient oral therapy with cefixime can lead to substantial reductions in healthcare expenditures.
- This approach supports cost containment and reduces risks associated with hospitalization.
Background:
The standard recommendation for treatment of young, febrile children with urinary tract infection has been hospitalization for intravenous antimicrobials. The availability of potent, oral, third-generation cephalosporins as well as interest in cost containment and avoidance of nosocomial risks prompted evaluation of the safety and efficacy of outpatient therapy.
Methods:
In a multicenter, randomized clinical trial, we evaluated the efficacy of oral versus initial intravenous therapy in 306 children 1 to 24 months old with fever and urinary tract infection, in terms of short-term clinical outcomes (sterilization of the urine and defervescence) and long-term morbidity (incidence of reinfection and incidence and extent of renal scarring documented at 6 months by 99mTc-dimercaptosuccinic acid renal scans). Children received either oral cefixime for 14 days (double dose on day 1) or initial intravenous cefotaxime for 3 days followed by oral cefixime for 11 days.
Results:
Treatment groups were comparable regarding demographic, clinical, and laboratory characteristics. Bacteremia was present in 3.4% of children treated orally and 5.3% of children treated intravenously. Of the short-term outcomes, 1) repeat urine cultures were sterile within 24 hours in all children, and 2) mean time to defervescence was 25 and 24 hours for children treated orally and intravenously, respectively. Of the long-term outcomes, 1) symptomatic reinfections occurred in 4.6% of children treated orally and 7.2% of children treated intravenously, 2) renal scarring at 6 months was noted in 9.8% children treated orally versus 7.2% of children treated intravenously, and 3) mean extent of scarring was approximately 8% in both treatment groups. Mean costs were at least twofold higher for children treated intravenously ($3577 vs $1473) compared with those treated orally.
Conclusions:
Oral cefixime can be recommended as a safe and effective treatment for children with fever and urinary tract infection. Use of cefixime will result in substantial reductions of health care expenditures.