Written by Rebecca DiFabio
Spoon Feed
This multicenter, double-blinded, non-inferiority trial found that short-course antimicrobial therapy had relatively low treatment failure rates compared to standard-course in children diagnosed with UTI who showed clinical improvement after 5 days of antibiotics.
Promising, but no shortcuts just yet
High-quality data regarding the duration of treatment in pediatric UTIs is lacking. The SCOUT RCT enrolled 664 children aged 2 months to 10 years who were afebrile and asymptomatic after 5 days of treatment for UTI. Exclusion criteria were extensive, summarized by the presence of multiple pathogens, complicated infection, or inability to follow-up. Patients were randomized to extension of the previously prescribed antimicrobial therapy or placebo, leading to either the standard 10-day course or a short, 5-day course.
The short-course group had a higher rate of treatment failure compared to the standard-course: 4.2% vs 0.6%; absolute risk difference 3.6% (upper 95%CI 5.5%) between day 6 and the first follow-up appointment (days 11-14). They set the upper CI at 5% for non-inferiority, which was exceeded (translation: standard course had lower treatment failure). Furthermore, there were higher rates of asymptomatic bacteriuria (95%CI 1.7-8.9, p<0.01) and positive urine cultures (95%CI 6.6-14.2, p<0.01) at or prior to the first follow-up visit in the short-course group. However, there was no statistically significant difference in UTI after the first follow-up visit (95%CI -2.6-3.3, p=0.97). Treatment failure, however, is hard to quantify, as the significance of asymptomatic bacteriuria and positive cultures may not equate to recurrent UTIs or clinical significance.
How will this change my practice?
I prescribe 7-day courses of antimicrobials for UTIs in children, which is within the range recommended by the American Academy of Pediatrics. Also, ensuring follow-up from the emergency department can be unreliable, and poor follow-up was an exclusion criterion in this study, limiting generalizability. In this age of antibiotic stewardship, however, exploration of shorter course treatments in the right patient population may be appropriate, with appropriate surveillance for treatment failures in place.
Peer Reviewed and edited by Ketan Patel and Clay Smith
Source
Short-Course Therapy for Urinary Tract Infections in Children: The SCOUT Randomized Clinical Trial. JAMA Pediatr. 2023 Jun 26:e231979. doi: 10.1001/jamapediatrics.2023.1979. Epub ahead of print.
