Testing Shorter Course of Treatment for Pediatric Urinary Tract Infection

Failure to resolve uncomplicated urinary tract infection (UTI) in children was less likely with a standard ten day course of treatment than with a short course of 5 days in a randomized trial, but investigators suggest that the shorter course can still be an appropriate choice for early responders.

"The low failure rate of short-course therapy suggests that it could be considered as a reasonable option for children exhibiting clinical improvement after 5 days of antimicrobial treatment," indicated study lead author Theoklis Zaoutis, MD, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, and colleagues.

The investigators characterize the SCOUT (Short Course Therapy for Urinary Tract Infections) trial as the largest to date to compare outcomes in children randomized to standard-course vs short-course antimicrobial therapy. They undertook the trial, they indicate, as the American Academy of Pediatrics endorses longer durations of antimicrobial therapy for UTI in children than are common in adults, and they find that the available data in pediatrics are "limited and contradictory."

"Additional pediatric-specific comparative data are needed to guide recommendations for optimal durations of therapy," Zaoutis and colleagues assert.

The investigators identified children 2 months to 10 years of age who were diagnosed with UTI and treated with oral antibiotics in outpatient clinics or emergency departments of 2 children's hospitals in Philadelphia from May 2012 through August 2019. They randomized 693 children who clinically improved at 5-day follow-up to either continue the prescribed antibiotic for an additional 5 days (standard 10 days of treatment) or to receive placebo after the 5 day, short-course of treatment.

Of 665 randomized children remaining for analysis of the primary outcome of whether a UTI was present between day 6 and the day 11 to 14 visit, 2 of 328 assigned to standard-course (0.6%) and 14 of 336 assigned to short-course (4.2%) had a treatment failure (absolute difference of 3.6% with high range 95% CI of 5.5%).

"Children receiving short-course therapy were more likely to have asymptomatic bacteriuria or a positive urine culture at or by the first follow-up visit," Zaoutis and colleagues reported. They noted, however, that the 4.2% might be considered a sufficiently low rate to discontinue the antibiotic for those without clinical symptoms after 5 days of treatment.

In an accompanying editorial, Aaron Milstone, MD, MHS and Pranita Tamma, MD, MHS, Division of Pediatric Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, point out several aspects about the trial that, they caution, should be considered "before determining how we can apply the results to clinical practice."

Among these, include:

• Not differentiating upper (typically requiring longer treatment) from lower tract disease—albeit a "challenging" differential in young children
• Including a range of antimicrobial regimens "with differing degrees of oral bioavailability (which) complicates the interpretation of findings"
• Employing different follow-up times for the two arms, despite that "the risk of failure is more likely after discontinuation of antibiotics"

These limitations notwithstanding, Milstone and Tamma find that the SCOUT trial, "is an important addition to the scientific literature to guide shared decision making between health care professionals and primary caretakers."

Although there is an increased risk of treatment failure with the short course, there is also less likelihood of adverse events, say Milstone and Tamma. They recommend that these considerations be weighed with parents."In this way, they can contribute to conversations surrounding the ultimate duration of therapy prescribed."