July 20, 2011 — The management of febrile urinary tract
infections in children is changing, according to the results of a clinical
review published in the July 21 issue of the New England Journal of
Medicine.
"Acute pyelonephritis is the most common serious
bacterial infection in childhood; many affected children, particularly
infants, have severe symptoms," write Giovanni Montini, MD, from the
Department of Pediatrics, Azienda Ospedaliero–Universitaria Sant'Orsola-Malpighi
in Bologna, Italy, and colleagues. "Most cases are readily treated,
provided diagnosis is prompt, though in some children fever may take several
days to abate. Approximately 7 to 8% of girls and 2% of boys have a urinary
tract infection during the first 8 years of life."
In boys as well as girls, febrile urinary tract infections
occur most often during the first year of life, unlike nonfebrile urinary
tract infections, which occur mostly in girls older than 3 years. After
infancy, urinary tract infections involving only the bladder usually present
with localized symptoms and are easily treated. When fever accompanies urinary infection, risk is greater for
kidney involvement, and underlying nephrourologic abnormalities are more
common, resulting in a higher risk for renal scarring and associated
substantial long-term morbidity. The
sensitivity of fever to predict renal involvement is 53% to 84%, and
specificity is 44% to 92%.
Management approaches for children with proven kidney
infections have involved intensive workup and treatment, often including
surgery and/or long-term antibiotic prophylaxis. Because experts have
questioned the need for such strategies, various recent or ongoing trials are
investigating optimal strategies for the evaluation and treatment of a first
febrile urinary tract infection, as well as the best options for subsequent
interventions.
In most children, oral and intravenous antibiotics appear
to be equally effective in treating febrile urinary tract infections. Current
recommendations of the American Academy of Pediatrics are that parenteral
antibiotic therapy and hospitalization be considered for children who appear
to be severely ill or dehydrated, or who cannot retain oral intake.
Although antibiotic choice depends on resistance patterns
in a given institution or region, cephalosporins
and amoxicillin–clavulanic acid are the oral antibiotics most often used, and
cephalosporins and aminoglycosides are often recommended for intravenous
treatment.
Thanks to advances in prenatal ultrasonography, it is now
known that significant renal damage
in children is often associated with the presence of hypodysplasia and other
urologic abnormalities. In some children, renal scarring associated
with infection results in additional damage to dysplastic kidneys or late
effects in kidneys that previously were normal.
"The value of antibiotic prophylaxis has been
questioned in recent studies," the review authors write.
"Further data are needed to determine which children might benefit from
antibiotic prophylaxis. Studies in progress may help to answer these
questions."
Dr. Montini reports that his prior institution, Azienda
Ospedaliera di Padova, has received grant support from AstraZeneca, but no
other potential conflict of interest relevant to this article was reported.
N Engl J Med.
2011;365:239-250.
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