Oral versus initial intravenous therapy for urinary tract infections in young febrile children.

Background The standard recommendation for treatment of young, febrile children with urinary tract infection has been hospitalization for intravenous antimicrobials. The availability of potent, oral, third-generation cephalosporins, as well as interest in cost containment and avoidance of nosocomial risks prompted evaluation of the safety and efficacy of outpatient therapy.

Methods In a multicentre, randomized clinical trial, the investigators evaluated the efficacy of oral versus initial intravenous therapy in 306 children 1 to 24 months old with fever and urinary tract infection, in terms of short-term clinical outcomes (sterilization of the urine and defervescence) and long-term morbidity (incidence of reinfection and incidence and extent of renal scarring documented at 6 months by ^99mTc-dimercaptosuccinic acid renal scans). Children received either oral cefixime for 14 days (double dose on day 1) or initial intravenous cefotaxime for 3 days followed by oral cefixime for 11 days. Costs were estimated using charge-data.

Results Treatment groups were comparable regarding demographic, clinical, and laboratory characteristics. Of the short-term outcomes: (1) repeat urine cultures were sterile within 24 h in all 306 children, and (2) mean time to defervescence was 25 and 24 h for children treated orally and intravenously, respectively. Of the long-term outcomes: (1) symptomatic re-infections occurred in 4.6% of children treated orally and 7.2% of children treated intravenously; (2) renal scarring at 6 months was noted in 9.8% of children treated orally versus 7.2% of children treated intravenously; and (3) mean extent of scarring was ~8% in both treatment groups. Mean costs were at least twofold higher for children treated intravenously ($3577 versus $1473) compared with those treated orally.

Conclusions Oral cefixime can be recommended as a safe and effective treatment for children with fever and urinary tract infection. Use of cefixime will result in substantial reductions of health care expenditures.