Comparative Effectiveness of Antibiotic Treatment Duration in Children With Pyelonephritis

Abstract

IMPORTANCE National guidelines recommend treating children with pyelonephritis for 7 to 14 days of antibiotic therapy, yet data are lacking to suggest a more precise treatment duration. OBJECTIVE To compare the clinical outcomes of children receiving a short-course vs a prolongedcourse of antibiotic treatment for pyelonephritis. DESIGN, SETTING, AND PARTICIPANTS Retrospective observational study using inverse probability of treatment weighted propensity score analysis of data from 5 hospitals in Maryland between July 1, 2016, and October 1, 2018. Participants were children aged 6 months to 18 years with a urine culture growing Escherichia coli, Klebsiella species, or Proteus mirabilis with laboratory and clinical criteria for pyelonephritis. EXPOSURES Treatment of pyelonephritis with a short-course (6 to 9 days) vs a prolonged-course (10 or more days) of antibiotics. MAIN OUTCOMES AND MEASURES Composite outcome of treatment failure within 30 days of completing antibiotic therapy: (a) unanticipated emergency department or outpatient visits related to urinary tract infection symptoms, (b) hospital readmission related to UTI symptoms, (c) prolongation of the planned, initial antibiotic treatment course, or (d) death. A subsequent urinary tract infection caused by a drug-resistant bacteria within 30 days was a secondary outcome. RESULTS Of 791 children who met study eligibility criteria (mean [SD] age 9.2 [6.3] years; 672 [85.0%]) were girls, 297 patients (37.5%) were prescribed a short-course and 494 patients (62.5%) were prescribed a prolonged-course of antibiotics. The median duration of short-course therapy was 8 days (interquartile range, 7-8 days), and the median duration of prolonged-course therapy was 11 days (interquartile range, 11-12 days). Baseline characteristics were similar between the groups in the inverse probability of treatment weighted cohort. There were 79 children (10.1%) who experienced treatment failure. The odds of treatment failure were similar for patients prescribed a short-course vs a prolonged-course of antibiotics (11.2% vs 9.4%; odds ratio, 1.22; 95% CI, 0.75-1.98). There was no significant difference in the odds of a drug-resistant uropathogen for patients with a subsequent urinary tract infection within 30 days when prescribed a short-courses vs prolonged-course of antibiotics (40% vs 64%; odds ratio, 0.36; 95% CI, 0.09-1.43). CONCLUSIONS AND RELEVANCE The study findings suggest that short-course antibiotic therapy may be as effective as prolonged-courses for children with pyelonephritis, and may mitigate the risk of future drug-resistant urinary tract infections. Additional studies are needed to confirm these findings.

Management of Pediatric Urinary Tract Infections: A Delphi Study

“…Accordingly, different studies investigated the effectiveness of shorter antibiotic regimens in pediatric population. A recent observational study in children reported that 6–9 days of antibiotic treatment is as effective as a longer duration of 10 days in patients affected by febrile UTI [ 79 ]. Outcomes of even shorter courses (1–3 days) are inferior to those of longer courses [ 23 ].…”

Global and Regional Burden of Bacterial Antimicrobial Resistance in Urinary Tract Infections in 2019

“…Based on the counterfactual scenario of non-infection, AMR in UTI was the fourth most infectious syndrome leading to AMR-related cause of death globally, just behind lower respiratory infections and all related infections in the thorax, bloodstream infections, and peritoneal and intra-abdominal infections [ 4 ]. Additionally, the disease burden of UTI is increasing [ 9 ], and antibiotics are usually recommended for the treatment of UTI [ 14 , 15 , 16 ] and as prophylactics, such as during prostate biopsy [ 17 ] and urological surgery [ 18 ]. Considering these facts, AMR in UTI is a health problem that cannot be ignored, both for the management of urology disease and for global antibiotic resistance.…”

Short versus prolonged antibiotic treatment for complicated urinary tract infection after kidney transplantation

“…Previous studies evaluating duration of antibiotic therapy for complicated UTI or Gram‐negative bacteraemia in general population demonstrate noninferiority of short (≤7 days) versus longer treatment (>7 days) [18,20,23]. A recent retrospective observational study examining treatment duration in pyelonephritis in children, showed no difference in odds of treatment failure for patients prescribed a short course (6–9 days) versus a prolonged course (≥10 days) of antibiotics (11.2% vs. 9.4%; odds ratio, 1.22; 95% CI, 0.75–1.98) [24].…”