27 The Ambulatory Parenteral Treatment of Uncomplicated Febrile Urinary Tract Infections in Children Using Ceftriaxone

We describe our experience using Ceftriaxone for ambulatory IV treatment of uncomplicated febrile UTI in children.

In a pilot project which began Sept. 1st, 2003, we offered ambulatory treatment of febrile UTI in children using IV ceftriaxone.

Children 3 months of age or older, non-toxic and febrile at initial presentation. Mild dehydration correctable in the ED was acceptable. Parents had to be reliable and willing to pursue outpatient treatment. Ineligible: Children with toxic appearance, moderate dehydration, renal failure or comorbidity.

Pathologies excluded from outpatient treatment: grade IV-V vesicoureteral reflux (VUR), grade III-IV hydronephrosis, nephrostomy/vesicostomy tubes, single kidney, posterior urethral valves, horse-shoe kidney, neuro-genic bladder and known kidney stones.

Children were referred by physicians in the ED according to a treatment algorithm developed by the Intensive Ambulatory Care Service (IACS). Treatment in the ED was Ceftriaxone 50 mg/kg IV and Ampicillin 50 mg/kg IV. Patients were discharged to IACS on po amoxicillin (to cover enterococcus). Parents were given an instruction card and 24-hour telephone number to speak to a nurse for concerns during treatment. Subsequent evaluation and treatment were performed by physicians and nurses in the IACS. Ceftriaxone and amoxicillin were continued until culture and sensitivities were available. Parenteral treatment was stopped once patients were 24 hours afebrile. Radiological evaluation including renal ultrasound, VCUG and DMSA were requested as needed.

Results are available for the first 15 patients referred to IACS for presumed UTI. Data on a larger sample will be presented. Twelve of 15 patients had culture-confirmed UTI. Diagnoses in the 3 non-UTI patients were: salmonella bacteremia in a 5-yr-old girl, non-specific febrile illness in a 2-yr-old girl and febrile vaccine reaction in a 4-mos-old girl. Age distribution of cases: 5 cases 3–24 mos, 1 case 2–5 yrs and 6 cases >5 yrs. Mean duration of IV treatment: 2.7 days (range 1–5 d). Nine of 12 patients were treated for their first episode of UTI. Investigations in these cases revealed a right gr. 1 VUR in a 5 mos-old girl and a urachal remnant in a 4 mos-old boy. The 3 patients with previous history of UTI were known to the urology service: a 9-yr-old girl with dysfunctional voiding, a 9 yr-old girl with enuresis/encopresis and an 11 yr-old girl with chronic constipation. There were no complications. All patients completed their course of treatment as outpatients.

Early results support the ambulatory treatment of children >3 months of age with uncomplicated febrile UTI using IV Ceftriaxone, provided patients are carefully selected and assessed daily by a physician.