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More focused approach suggested for management of UTI in neonates

An evaluation was conducted to determine if the current recommended treatment regimen for nontoxic, febrile neonates with presumptive UTI is justified.

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December 1999

SAN FRANCISCO - The current approach for neonates with presumptive urinary tract infection (UTI) who are at otherwise low risk for sepsis or meningitis is probably overly aggressive, according to researchers at Children's Hospital of Orange County, Calif.

They presented their approach to the management of UTI in neonates at a poster presentation during the 39th Interscience Conference on Antimicrobial Agents and Chemotherapy.

Current standards of practice dictate an extensive work-up for sepsis on neonates with presumptive UTI, which includes lumbar puncture followed by parenteral antibiotic therapy. The rationale is that UTI in neonates is considered to be secondary to hematogenous seeding.

"This approach can lead to unnecessary invasive procedures, prolonged hospitalization, overutilization of laboratory resources and needless prolonged parenteral antimicrobial treatment," said lead investigator Antonio C. Arrieta, MD, pediatric infectious diseases at Children's Hospital.

The investigators conducted an evaluation to determine if the current recommended aggressive work-up and treatment regimen for nontoxic, febrile neonates with presumptive UTI are justified.

The records of neonates (0 to 30 days) discharged with a diagnosis of UTI were reviewed. The patients' signs and symptoms, laboratory/X-ray evaluation and antibiotic treatments were recorded. Seventy neonates met the criteria, 52 of whom were febrile. None of the neonates was toxic. All 70 had urine cultures, of which 61 were positive. Escherichia coli was the most frequent pathogen; 72% of positive cultures had E. coli.

"Similar to older children and adults with ascending UTI. E. coli and other gram-negative rods are the most frequent pathogens in neonatal UTI," said Arrieta. Nine patients with negative cultures had pyuria.

Four patients received antibiotics prior to cultures. Urinalysis was positive in 84% of neonates with positive urine cultures. Twenty of 66 neonates with blood cultures had positive blood cultures. "Seven positive blood cultures with organisms likely to be pathogens were distributed evenly among patients with different degrees of fever and leukocytosis," he said.

A lumbar puncture was performed in 61 of the neonates. Fifteen of the spinal taps were traumatic and could not be interpreted; eight neonates had pleocytosis. None of the cerebrospinal fluid (CSF) cultures yielded the same bacteria as the blood and/or urine cultures.

There was no uniformity in the antibiotics chosen to treat pyelonephritis. Ampicillin and cefotaxime (Claforan, Hoechst Marion Roussel) was started in 66%, cefotaxime in 11%, ceftriaxone (Rocephin, Roche) in 11% and ampicillin/gentamicin in 9%. "Based on pathogens recovered from blood and urine cultures, a third-generation cephalosporin would be an appropriate choice," the researchers suggested.

All follow-up cultures during therapy were negative. The average length of intravenous (IV) antibiotic therapy was 5.3 days. IV antibiotics were given for 10 to 21 days in neonates with positive bladder cultures/CSF pleocytosis. Most were discharged on oral antibiotics.

Ultrasound was positive in 37 of 70 patients but the results never affected management. A vesicoureterogram was done on only 39 patients; four of whom had grade 3 or greater reflux. Too often, important radiologic evaluation is not performed due to poor compliance, said the researchers.

Managing Urinary Tract Infections

The researchers suggest the following course to minimize invasive procedures yet assure the safe and cost-effective management of UTI in neonates. All neonates should receive urinalysis and urine and bladder cultures when being evaluated for bacterial infection. If urinalysis is positive, nontoxic patients are at low risk of meningitis and probably don't require lumbar puncture. Lumbar puncture should be reserved for patients likely/confirmed to be bacteremic with a presumed pathogen (concordant blood/urine pathogen). Ampicillin is unnecessary. Follow-up urine cultures during therapy are not warranted. Routine ultrasound for UTI is redundant and should be limited to high-risk patients (high blood pressure, palpable abdominal mass, abnormal genital-urinal exam, abnormal renal function test, abnormal voiding patterns). A vesicoureterogram should be performed, preferably prior to discharge if unreliable follow-up is suspected. Healthy neonates with UTI can be managed with a five-day or less course of IV antibiotics and discharged on oral antibiotics if good follow-up is ensured.

For more information:

• Butler J, Ashouri N, Vargas-Shiraishi OM, Singh J, Arrieta AC. New approach to the management of urinary tract infection in neonates. A challenge to current dogmas. Presented at the 39th Interscience Conference on Antimicrobial Agents and Chemotherapy. Sept. 26-29. San Francisco.

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Copyright 2000, SLACK Incorporated. Revised 15 September 2000.