Young children with acute urinary tract infections (UTIs) typically are hospitalized for intravenous antibiotic therapy. Effective oral therapy would eliminate the costs, risks and trauma associated with hospitalization. Hoberman and colleagues compared the effectiveness of an oral antibiotic with that of an intravenous antibiotic in treating UTIs in this population.
Children between one and 24 months of age were eligible for the study if they had a rectal temperature of at least 38.3°C (100.9°F), along with pyuria and bacteriuria. A positive culture (defined as a single pathogen with at least 50,000 colony-forming units) from a catheterized urine specimen was a final requirement for inclusion. Exclusion criteria included a history of UTI, urinary tract abnormalities, underlying chronic disease or gram-positive cocci in the urine. Patients who met the study criteria were randomized by age and duration of fever to receive cefotaxime (200 mg per kg per day) intravenously in the hospital or cefixime (16 mg per kg on day 1 and 8 mg per kg per day on days 2 through 14) on an outpatient basis. Hospitalized patients were switched to oral cefixime (8 mg per kg per day) on day 4 or after they were afebrile for 24 hours, whichever was longer. Follow-up examination and repeat urine culture were performed in the hospital after 24 hours. Subsequent evaluation was done by telephone after 48 hours and again after 10 days. Renal scans were obtained at baseline and at six months to assess for scarring or acute pyelonephritis. Renal ultrasonography was also performed as part of the imaging studies. Urine cultures were obtained at three and six months, and whenever patients had a febrile illness.
A total of 322 children was included in the study. Escherichia coli was the most common isolate found in the urine cultures. Almost one half (40 percent) of the isolated microorganisms were resistant to ampicillin and amoxicillin. Patients found to have bacteremia tended to be younger and to have a longer duration of fever than those without bacteremia. The incidence of reinfection did not differ significantly between groups. All follow-up renal scans were normal in children whose baseline scans were normal. In addition, the cost of inpatient treatment was twice as high as that for outpatient treatment.
The authors conclude that oral cefixime is as safe and effective as intravenous cefotaxime in treating UTI in young febrile children. Outpatient management not only reduces health care costs, it is less traumatic for the patient and family. Oral cefixime is a viable alternative because it is not associated with poor outcomes or long-term sequelae as was once thought to occur with what was perceived to be less aggressive treatment.
editor's note: In an accompanying editorial, Fisher applauds the findings of the Hoberman study. She also cautions that cefixime, although appropriate for empiric therapy of UTI, has a spectrum that is too broad once susceptibility studies are available. At that point, patients should be switched to a narrow-spectrum antibiotic.—g.b.h.