Understanding Urosepsis and Renal Scarring in Pediatric UTIs

Reference: Zaoutis T, et al. Short-course Therapy for Urinary Tract Infections in Children: the SCOUT randomized clinical trial. JAMA Pediatr. Aug 2023 Date: October 30, 2023 Dr. Ellie Hill Guest Skeptic: Dr. Ellie Hill is a pediatric emergency medicine physician at Children’s National Hospital in Washington, DC and Assistant Professor of Pediatrics and Emergency Medicine at George Washington University School of Medicine and Health Sciences. Her research interests include improving the diagnosis of urinary tract infections in children. Case: A 4-year-old girl comes to the emergency department complaining of pain with urination. She has not had any fevers or flank pain. The last time she had these symptoms a year ago, she was diagnosed with a urinary tract infection (UTI) and started on antibiotics. You obtain a urinalysis that demonstrates 43 white blood cells, positive leukocyte esterase, and positive nitrites. You tell the family the results of the urinalysis and let them know that she likely has another UTI, and you plan to prescribe some antibiotics. Her parents reply, “Last time she had to take over a week of antibiotics for her UTI, and she had bad diarrhea. Is it possible that we do a shorter treatment if she needs antibiotics?” Background: Does it seem like antibiotic courses are getting shorter these days? We covered short-course treatment for pediatric pneumonia in the SAFER trial with Dr. Andrew Tagg back on SGEM #338 and the SCOUT-CAP trial on SGEM #359. UTIs are one of the most common bacterial infections in childhood that we see in the emergency department [1]. The American Academy of Pediatrics (AAP) released guidelines for the management of febrile infants and children 2 to 24 months back in 2011 [2]. In those guidelines, they included the statement “The clinician should choose 7 to 14 days as duration of antimicrobial therapy.” However, the optimal antibiotic duration for the treatment of UTI is still uncertain [3]. Clinical Question: What is the efficacy of short-course (5-day) vs standard-course (10-day) antibiotic therapy for children with urinary tract infections? Reference:  Zaoutis T, et al. Short-course Therapy for Urinary Tract Infections in Children: the SCOUT randomized clinical trial. JAMA Pediatr. Aug 2023 Population: Children 2 months to 10 years with and without febrile UTI exhibiting clinical improvement after 5 days of antimicrobials Excluded: Second uropathogen (>104 CFU by catheterization or suprapubic aspiration, or >5x104 CFU by clean catch), hospitalization for bacteremia, admission to ICU, urine culture with pathogen resistant to initially prescribed antimicrobial, catheter-associated UTI, history of UTI within 30 days, phenylketonuria, congenital or anatomy abnormality of the GU tract other than grade I to II vesicoureteral reflux, duplicated collecting systems, or hydronephrosis, previous GU surgery, unable to tolerate PO medications, immunocompromise, Type I hypersensitivity or anaphylaxis to study products, gestation <36 weeks for children younger than 2, inability to attend follow up Intervention: Additional 5 days of antimicrobial therapy (10 days total, standard course) Comparison: Additional 5 days of placebo (5 days total, short-course) Outcome: Primary Outcome: Treatment failure is defined as symptomatic UTI at or before the first follow-up visit (day 11 to 14) Secondary Outcomes: UTI after first follow-up visit, asymptomatic bacteriuria, positive urine culture, gastrointestinal colonization with resistant organisms Trial: Multicenter, randomized, double-masked, placebo-controlled noninferiority clinical trial Authors’ Conclusions: “In this randomized clinical trial, children assigned to standard-course therapy had lower rates of treatment failure than children assigned to short-course therapy. However, the low failure rate of short-course therapy suggests that it could be considered as a reasonable op...