COMMENTARY

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

Sonali D. Advani, MD, MBBS, MPH

Disclosures

July 12, 2018

Editorial Collaboration

Medscape &

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.

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