Can children with uncomplicated urinary tract infections be successfully treated with short courses of antibiotics?
In this study, standard-course therapy for children with UTI was superior to short-course therapy. However, the number needed to treat of 28 suggests that offering short-course therapy is not unreasonable, especially if there is good follow-up in the subsequent weeks.
Plan de l'etude:
Randomized controlled trial (double-blinded)
These researchers recruited children (aged 2 months to 10 years) within 2 to 5 days of being given a diagnosis of an uncomplicated urinary tract infection (UTI) who were being treated with amoxicillin-clavulanate, cefixime, cefdinir, cephalexin, or trimethoprim-sulfamethoxazole. On the fifth day, the researchers randomized the children who were improving (asymptomatic and afebrile) to receive 5 more days of the antibiotic (standard-course therapy, n = 348) or to 5 days of a matching placebo (short-course therapy, n = 336). For reference, the American Academy of Pediatrics guideline does not recommend tests of cure in this age group. Researchers masked to treatment assignment did in-person evaluations of the children 11 days to 14 days and 24 days to 30 days after the initial treatment. In addition to the clinical assessments, the researchers also collected urine samples for culture. The main outcome, treatment failure, was defined by all of the following: any symptoms or signs of UTI; pyuria (10 or more white blood cells/cubic milliliter or 5 or more white cells/high-powered field, each on centrifuged samples or trace or greater leukocyte esterase on a dipstick); a positive urine culture. Using a modified intention-to-treat analysis, the authors report that treatment failure occurred in 0.6% of children treated with standard courses and 4.2% of those treated with short courses. This investigation was set up as a noninferiority trial and the data do not support the noninferiority of short-course therapy. However, one would need to treat 28 children with standard-course therapy to prevent 1 treatment failure (95% CI 16 - 80). There was no statistically significant difference in the proportion of children with UTI symptoms on days 6 through 14 (9.1% vs 12.2%). Additionally, the outcomes did not differ by specific antibiotics. The rate of adverse events was similar in each group (47.3% and 43.8%, respectively).
Henry C. Barry, MD, MS
Michigan State University
East Lansing, MI