In a randomised trial in Italy, five days of an oral antibiotic was as effective as 10 days. 

Most children with uncomplicated febrile urinary tract infection (UTI) receive oral antibiotics, typically for 10 days. But is this traditional duration evidence based? In a multicentre trial, Italian investigators assessed recurrent infection within 30 days of completing five-day versus 10-day treatment courses. Secondary end points were clinical response, adverse events and antibiotic resistance.

In all, 140 children with febrile UTIs were randomised one to one on day five of antibiotic treatment (amoxicillin-clavulanate) to either stopping therapy or adding an additional five days of antibiotics, with follow up for microscopic urine examination five and 30 days, respectively, after antibiotic completion. Key findings were:

• Esherichia coli was the primary causative organism in both the five- and 10-day treatment groups (86.1% and 88.6%, respectively)
• UTI recurrence rates within 30 days of treatment completion were 2.8% (five-day treatment) vs 14.3% (10-day treatment); rates of febrile UTI recurrence were 1.4% vs 5.7%
• both groups had similar resolution of signs and symptoms (97.2% and 92.9%), with additional antibiotic therapy required in 1.4% and 8.6%
• adverse events were similarly uncommon in both groups
• likelihood of resistant organisms emerging after therapy was very low in both groups.

Comment: Antibiotic duration for most infections often feels etched in stone. Studies such as this provide reassuring evidence that fewer days of antibiotics may be as effective as (and perhaps even better than) longer courses. Given the benefits of reduced antibiotic exposure, physicians should consider treating uncomplicated febrile UTIs in children for five days rather than the more traditional 10 to 14 days. As an editorialist notes, the sample size in this study was relatively small; thus, additional larger studies will be important to confirm best practice, particularly for children with pyelonephritis.

Deborah Lehman, MD, Clinical Professor of Pediatrics and Assistant Dean of Student Affairs, David Geffen School of Medicine, University of California, Los Angeles, USA.

Montini G, et al. Short oral antibiotic therapy for pediatric febrile urinary tract infections: a randomized trial. Pediatrics 2024; 153: e2023062598.

Woods CR, Atherton JG. Are we ready for short antibiotic courses for febrile urinary tract infections in young children? Pediatrics 2024 Jan; 153: e2023063979.

This summary is taken from the following Journal Watch title: Infectious Diseases.