Ambulatory treatment of infants with presumed febrile urinary tract infection may be feasible

Dore-Bergeron MJ, Gauthier M, Chevalier I, McManus B, Tapiero B, Lebrun S. Urinary tract infections in 1- to 3-month-old infants: ambulatory treatment with intravenous antibiotics. Pediatrics 2009;124:16-22.

Question 

Among 1- to 3-month-old infants with febrile urinary tract infection (UTI), can they successfully be treated as outpatients?

Design 

Retrospective cohort study.

Setting 

A tertiary care pediatric center in Canada.

Participants 

One hundred eighteen eligible infants, age 30 to 90 days, with presumed diagnosis of febrile UTI seen in the emergency department. Exclusion criteria for outpatient treatment were age less than 30 days, toxic appearing, dehydration, abnormal cerebrospinal fluid, previous urinary tract surgery, questionable parent compliance, or other medical conditions.

Intervention 

Participants received intravenous ampicillin, gentamicin, and oral amoxicillin and were seen within 24 hours and then daily at the day treatment center (DTC). Antibiotics were given orally once culture results were available and the patient was fever-free for 24 hours. Investigations for the first UTI were renal ultrasonography and voiding cystourethrography.

Outcomes 

Assessment of whether infant age was associated with successful implementation of protocol; the appropriateness of patient referral; and successful treatment at the DTC.

Main Results 

Of 118 infants included in the study, 67 (56.8%) were admitted to the DTC, and 51 (43.2%) were hospitalized. The mean duration of antibiotics of 2.7 days at the DTC, and the mean length of stay for hospitalized patients was 3.9 days. Two patients at the DTC should have been admitted for abnormal cerebrospinal fluid, but culture results were negative. Eighty-seven percent of patients at the DTC had a final diagnosis of UTI (probable in 17%), 98% had fever resolution within 48 hours. Seven patients were hospitalized from the DTC, most commonly for bacteremia but were clinically stable. There was an increase in hospitalization rate in younger infants, which was not significant. Successful treatment in the DTC (defined as attendance at all visits, normalization of temperature within 48 hours, negative control urine and blood culture results, if cultures were performed, and absence of hospitalization from the day treatment center) was obtained for 86.2% of patients with confirmed UTI.

Conclusions 

Ambulatory treatment of infants 30 to 90 days of age with febrile UTI by use of short-term, intravenous antibiotic therapy at a day treatment center is feasible.

Commentary 

This study examined the feasibility of treating infants with presumed febrile UTI as outpatients with parenteral antibiotics, and the authors outline a system that ensures close follow-up and was without significant complications in their cohort. The economic implications of this study are relevant in today's healthcare environment. However, the patients were initially triaged by pediatricians in the ED, and the DTC was staffed by pediatric hospitalists and pediatric nurses 7 days a week, which may not be feasible at all centers. In addition, the authors describe the clinical course for the patients treated as outpatients but did not describe the course for those treated as inpatients, or more specifically, the patients who would have qualified for outpatient therapy. Finally, the authors did not describe how the diagnosis of presumed febrile UTI was made. Traditionally, infants younger than 90 days of age are admitted for treatment of febrile illness because of the increased risk of bacteremia and the inability to distinguish infants with bacteremia on clinic grounds. The previously published Rochester criteria provide guidance to clinicians about what infants are at low risk for serious bacterial infection with the objective criteria of physical examination, white blood cell and band count, and urinalysis.1 In this study, the mean white blood cell count for each group was shown in table form, but it was not stated whether this was factored into the decision to admit or discharge these young febrile infants and the urinalysis results were not provided.