Initial Parenteral then Oral Antibiotic vs Oral Alone in Pediatric UTI

Written by Clay Smith

Spoon Feed
There was no reduction in 72-hour repeat ED visit with subsequent admission for children 29 days - 2 months who were given a single parenteral dose of antibiotic in the ED and then outpatient oral treatment vs simply starting on oral therapy.

Why does this matter?
The AAP Clinical Practice Guideline on management of UTI in febrile children 2-24 months states explicitly, “initiating treatment orally or parenterally is equally efficacious.” But often a “shot” of antibiotic is given in the ED prior to departure, thinking this will get the child off to a strong start before initiating oral antibiotics at home. But does this help?

“I don’t wanna get a shot!,” said the child who read this study…
This was a retrospective study of 29,919 children, 29 days to 2 years of age, from 36 children’s EDs. They found no difference in adjusted 72-hour return to the ED with subsequent admission in the 36% who had a single dose of parenteral antibiotic prior to discharge on oral antibiotics, as opposed to those who were just started on oral treatment with no parenteral dose. The crude, unadjusted rate of return with admission was significantly greater in those who received parenteral antibiotics (1.8% vs. 0.7%, difference 1.1% [95%CI, 0.8-1.4]). Overall adjusted bounceback to the ED (all returns, not just return with admission) was higher in those who got a parenteral dose vs not (4.8% vs 3.3% = 1.5% difference [95%CI, 0.9-2.0]). Of course, this is retrospective, so we don’t know why a parenteral dose was given. Younger infants were more likely to get a parenteral dose. It is impossible to know whether readmission would have been even higher had this not been given. Though this is a lower level of evidence, it suggests that giving kids a shot of antibiotics rather than just starting oral therapy is unhelpful.

Another Spoonful
A similar study was done in adults, with more antibiotic-associated diarrhea in the IV group.

Source
Emergency Department Revisits After an Initial Parenteral Antibiotic Dose for UTI. Pediatrics. 2018 Sep;142(3). pii: e20180900. doi: 10.1542/peds.2018-0900. Epub 2018 Aug 21.

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