When you diagnose an otherwise healthy child 3 months to 5 years of age with a urinary tract infection (UTI), can you treat for only 5 or 10 days, instead of the currently recommended 7 to 14 days? To answer the effectiveness, Montini et al. share with us the results of the “Short-course Oral Antibiotic Therapy Of Acute Pyelonephritis (STOP)” trial in an article being early released this month in Pediatrics (10.1542/peds.2023-062598).
The authors report on 142 children between the ages of 3 months to 5 years with uncomplicated UTI seen in 8 pediatric emergency departments in Italy between 2020 and 2022 who were randomized to receive amoxicillin-clavulanate in 3 divided doses for 5 or 10 days. The primary outcome was recurrence of UTI within 30 days of antibiotic completion. Secondary outcomes included adverse drug-related events, antibiotic resistance, and need for other antibiotics for UTI recurrence.
The recurrence rate was 2.8% in the 5-day short course group and 14.3% in the 10-day course group, which was not statistically different (ie, 5 days was not inferior). Clinical cure rates, adverse events, and antibiotic resistance were also not different.
Is this study sufficient to convince you to reduce the duration of treatment of UTIs in your younger patients? While the authors note limitations, including the sample size and the lack of blinding regarding treatment duration, the results are well worth knowing about. We invited infectious disease specialist Dr. Charles Woods and pediatric nephrologist Dr. James Atherton from University of Tennessee Health Sciences Center College of Medicine in Chattanooga to share their thoughts in an accompanying commentary (10.1542/peds.2023-063979).
Drs. Woods and Atherton point out the benefits of a shorter course on antimicrobial resistance, risk of adverse effects of therapy, costs, and potentially even long-term adverse changes to the microbiome. They also point out the potential risks of shorter treatment such as treatment failure and long-term consequences like renal scarring and hypertension.
In addition, Drs. Woods and Atherton note how the study by Montini et al. differs from another trial, the Scout Trial (Short-COurse Therapy for UTI in children) that involved 664 children and found treatment failure after two weeks in 4.2% who received short-course therapy versus 0.6% who received longer-term therapy. Drs. Woods and Atherton provide a terrific discussion regarding why the results of these two trials differ. They note differences in study populations and differences in the study definitions of UTI. They conclude in their commentary that the data in the STOP trial suggest that 5 days may be a good approach if you believe the child has cystitis and not pyelonephritis, based on the presence of fever. They also note that the key to trying a shorter course of treatment is close follow-up and making sure families understand the benefits and risks of a 5-day versus longer course of antibiotic treatment.
