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Nonresponders: prolonged fever among infants with urinary tract infections
1Division of Emergency Medicine, Children's Hospital, Boston, Massachusetts 02115, USA. bachur@a1.tch.harvard.edu
Insights
Most young children with febrile urinary tract infections (UTIs) improve within 48 hours of antibiotic treatment. Persistent fever beyond this point in febrile UTI cases did not correlate with more severe complications.
Area of Science:
- Pediatric Infectious Diseases
- Urology
- Clinical Medicine
Background:
- Febrile urinary tract infections (UTIs) are common in young children, often indicating pyelonephritis.
- Fever resolution is a key indicator of effective UTI treatment.
- Prolonged fever may suggest complications like urinary obstruction or renal abscess.
Purpose of the Study:
- To analyze fever patterns in children treated for febrile UTIs.
- To compare clinical features of children with prolonged fever versus those with faster fever resolution.
Main Methods:
- Retrospective medical record review of children aged 2 years or younger admitted with pyelonephritis or UTI.
- Exclusion of patients with prior UTIs, known urologic issues, or immunodeficiency.
- Definition of non-responders as those above the 90th percentile for time to defervescence.
Main Results:
- 89% of children became afebrile within 48 hours of antibiotic therapy.
- Children with prolonged fever (non-responders) were older but clinically similar to responders.
- Non-responders showed no increased likelihood of bacteremia, hydronephrosis, or significant vesicoureteral reflux.
Conclusions:
- Most young children with febrile UTIs respond to antibiotics within 48 hours.
- Persistent fever beyond 48 hours in febrile UTI patients does not appear to indicate more severe underlying conditions.
- Diagnostic studies or extended hospitalization solely for fever beyond 48 hours may not be necessary if antibiotic sensitivities are known.
Background:
The majority of young children with fever and urinary tract infections (UTIs) have evidence of pyelonephritis based on renal scans. Resolution of fever during treatment is 1 clinical marker of adequate treatment. Theoretically, prolonged fever may be a clue to complications, such as urinary obstruction or renal abscess.
Objective:
Describe the pattern of fever in febrile children undergoing treatment of a UTI. Compare the clinical characteristics of those patients with prolonged fever to those who respond faster to therapy.
Setting:
An urban pediatric hospital.
Design:
Medical record review.
Methods:
All children /=38 degrees C and those who met standard culture criteria were studied. Temperatures are not recorded hourly on the inpatient unit; therefore, they were assigned to blocks of time. Nonresponders were defined as those above the 90th percentile for the time to defervesce. Nonresponders were then compared with the balance of the study patients, termed responders.
Results:
Of 288 patients studied, the median age was 5.6 months (interquartile range: 1.3-7.9 months old). Median admission temperature was 39.3 degrees C (interquartile range: 38.5 degrees C-40.1 degrees C). Median time to defervesce ranged in the time block 13 to 16 hours. Sixty-eight percent were afebrile by 24 hours and 89% by 48 hours. Thirty-one patients had fever >48 hours (nonresponders). Nonresponders were older than responders (9.4 vs 4.1 months old) but had similar initial temperatures (39.8 vs 39.2 degrees C), white blood cell counts (18.4 vs 17.1 x 1000/mm(3)), and band counts (1.4 vs 1.2 x 1000/mm(3)). Nonresponders had similar urinalyses with regard to leukocyte esterase positive (23/29 vs 211/246), nitrite-positive (8/28 vs 88/221], and the number of patients with "too numerous to count" white blood cell counts per high power field (12/28 vs 77/220). Nonresponders were as likely as responders to have bacteremia (3/31 vs 21/256), hydronephrosis by renal ultrasound (1/31 vs 12/232), and significant vesicoureteral reflux (more than or equal to grade 3; 5/26 vs 30/219). Eschericia coli was the pathogen in cultures of 28 of 31 (nonresponders) and 225 of 257 (responders) cultures. The number of cultures with >/=100 colony-forming units/mL was similar (25/31 nonresponders vs 206/257 responders). Repeat urine cultures were performed in 93% of patients during the admission; all culture results were negative. No renal abscesses or pyo-hydronephrosis was diagnosed.
Conclusions:
Eighty-nine percent of young children with febrile UTIs were afebrile within 48 hours of initiating parenteral antibiotics. The patients who took longer than 48 hours to defervesce were clinically similar to those whose fevers responded faster to therapy. If antibiotic sensitivities are known, additional diagnostic studies or prolonged hospitalizations may not be justified solely based on persistent fever beyond 48 hours of therapy.