What's the Verdict for UTIs in Women and Children?

Antibiotic Choice in Urinary Tract Infection

Urinary tract infections (UTIs) pose a high burden to the health of women and children, incurring significant challenges in treatment and diagnosis, respectively. Two recent studies^[1,2] compared recommended treatments for acute uncomplicated cystitis in women and propose a new diagnostic algorithm to estimate the probability of UTIs in febrile children.

In a trial by Huttner and colleagues,^[1] 513 nonpregnant women aged 18 years and older with symptoms of lower UTI were randomly assigned to either 5 days of thrice-daily 100 mg nitrofurantoin or to a single 3-g dose of fosfomycin. The mean age of these women was 44 years. The primary outcome was a 28-day clinical response, but the microbiologic response was measured as a secondary outcome. In an intention-to-treat analysis, clinical resolution on day 28 was achieved in 70% of patients (171/244) who received nitrofurantoin versus 58% of patients who received fosfomycin (139/241), with a difference of 12% (P = .004). Microbiologic resolution occurred in 129/175 (74%) versus 103/163 (63%), respectively (difference, 11%; P = .04). Adverse events were few and primarily gastrointestinal—nausea and diarrhea (< 4% in each group).

A subgroup analysis in 214 women with confirmed Escherichia coli infections showed that clinical resolution at day 28 occurred in 78% of those taking nitrofurantoin versus 50% of those taking fosfomycin (difference, 28%; P < .001). Limitations of the study included its open-label design, the inclusion of microbiologic outcomes, and the use of different nitrofurantoin dosing, which may have influenced the results. The investigators concluded that among women with uncomplicated UTI, a 5-day course of nitrofurantoin was more likely to lead to clinical and microbiologic resolution compared with single-dose fosfomycin, and that the role of fosfomycin needs further scrutiny.

Febrile Children: Is It a UTI?

Another study, in JAMA Pediatrics,^[2] addresses the challenges of accurately estimating the probability of a UTI in febrile preverbal children. Shaikh and colleagues developed and validated a tool, called UTICalc. This calculator estimates the probability of a UTI in a child aged 2 months to < 2 years, based on clinical variables, and updates that probability on the basis of laboratory results. The calculator includes five dichotomous clinical risk factors (aged < 12 months, temperature ≥ 39° C, nonblack race, female or uncircumcised male, and no other fever source). The calculator provides the probability of UTI for a child with those characteristics and assigns a risk category (low or high).

Compared with the American Academy of Pediatrics algorithm, the clinical model in UTICalc reduced testing by 8.1% (95% confidence interval [CI], 4.2%-12.0%) and reduced the number of UTIs that were missed from three cases to none. Compared with empirically treating all children with a leukocyte esterase test result of 1+ or higher, the dipstick model in UTICalc reduced the number of treatment delays by 10.6% (95% CI, 0.9%-20.4%). The investigators concluded that UTICalc is a better approach to estimating the probability of UTI in children because it tailors testing and treatment to the individual child's risk factors.

Cite this: What's the Verdict for UTIs in Women and Children? - Medscape - Jul 12, 2018.

Commenting is limited to medical professionals. To comment please Log-in.

Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.