UTI Treatment

See NICE CG224 (refers then to CG111 (pyelonephritis) and CG109 (lower tract UTI)): Under 3 months get IV treatment. Else 3 days oral treatment if lower tract, 7-10 days oral for upper tract. IV for vomiting, unable to take oral or severe illness (but also says underlying known anomalies should influence choice) 2-4 days IV then oral for total of 10 days (!). No preference between cefuroxime, ceftriaxone and gentamicin. Upper tract defined as fever else loin pain/tenderness

Cochrane review concluded that 2-4 day course of oral antibiotic is as effective as a 7-14 day course in the treatment of lower-tract UTIs in children. PMID 12535494 The majority of febrile infants with UTI have nuclear scan evidence of pyelonephritis, suggesting that infants should not receive short course treatment.

Also concluded that for pyelonephritis oral antibiotics are as effective as the combination of parenteral followed by oral antibiotics. Based on:

  • Hoberman’s RCT children under 2 with fever and UTI (n=300) – oral cefixime for 2 weeks as good as IV: no difference in defervescence, reinfection, scarring at 6 months (and much cheaper!). Severely ill excluded (eg CRT>3sec) – only 3! Funny group though, mean age of 8 months, 90% female, and a low scarring rate (15%). Pediatrics 99 Vol. 104: 79, Hoberman A.
  • Montini Multicentre RCT non-inferiority (n=502, 1/12 to 7yrs). Oral co-amoxiclav for 10 days equivalent to ceftriaxone for three days followed by oral in terms of DMSA scars, time to defervescence. BMJ 2007; 335:386-8

Crucial that oral antibiotics are not vomited, of course.

Gauthier et al treated infants and toddlers with febrile UTIs as outpatients using a single daily dose of intravenous gentamicin until the children were afebrile for at least 24 hours, after which oral amoxicillin (!) was given until the urinary culture report was available. Successful in three quarters. Current Opinion in Pediatrics. 18(2):134-8, 2006

1/3 of UTI E coli resistant to trimethoprim, 2/3 if underlying renal abnormality. 61% of women with UTIs and resistant organisms do not reconsult! So should we use community surveillance to guide prescribing rather than individual culture and sensitivity?

UTI prophylaxis did not reduce recurrent infection (n=611). But lower rate (12%) reported than might be expected. Higher resistance rates are seen in recurrent infections, which could be anticipated (JAMA 2007;298;179)