“Such a plan is complex, so if the primary care physician or family was at all uncomfortable, admission to accomplish that plan would clearly be appropriate.
“A final issue not adequately addressed within the scenario is an assessment of the infant’s hydration—potentially an issue due to the vomiting. If the infant was mildly to moderately dehydrated with persistent vomiting, I would also then admit until this improved.
“In regard to the cited evidence, I would say that clearly an arbitrary cut-off of automatic admission under three months is not well supported by current literature, but is certainly many practitioners’ ‘style.’ Oral antibiotics are clearly efficacious for pyelonephritis, but the clinician needs to be confident the family can give them and the infant will keep them down. I believe most practitioners would agree with admission for an infant under 30 days, but where to precisely draw that line needs to be better established through investigation. Potential concomitant bacteremia and meningitis lead me to support obtaining blood and CSF cultures on any infant under 60 days for which I plan to initiate antibiotics for UTI.”
Possibility of Dehydration Indicates Admission
Michael P. Fullmer, DO, Central Iowa Pediatric Hospitalists, Mercy Medical Center, Des Moines, Iowa, responds: “This patient is not febrile, but does have other systemic symptoms, including poor feeding, irritability, jaundice, and vomiting. These systemic symptoms could be indicative of a serious bacterial infection like UTI, bacteremia, or meningitis. This patient most likely has a UTI. These symptoms may suggest pyelonephritis rather than lower UTI, but the distinction is not necessary for our decision here.
“Bacteremia is present in up to 22.7% of infants less than two months old with a UTI. This adds to the complexity of the issue, and a blood culture is probably indicated. Meningitis should be considered, but a lumbar puncture is probably not indicated in this scenario.
“A one-month-old with a UTI should be admitted to the hospital and started on parenteral antibiotics. There are several reasons for admission. First, the presence of vomiting makes oral antibiotic administration impractical (if not impossible). Intramuscular antibiotic injection may be an option, but the IV route gives the provider more options and is usually better accepted by parents. Next, if the patient is not already dehydrated, the poor feeding and vomiting could lead to dehydration. This alone would be an indication for admission. Finally, admission would give the physician time to observe the infant for clinical improvement. This may be subtle in the absence of fever.
“Another consideration is the recommended imaging for all children less than two years old. The AAP has recommended a renal ultrasound and VCUG for all infants and young children with their first UTI. This is important for discovery of urinary tract anomalies that predispose the patient to recurrent UTIs and eventual renal scarring and dysfunction. The imaging should be performed at the earliest convenient time if the patient is responding to therapy. In our practice, we generally have the renal ultrasound performed while the patient is in the hospital and arrange the VCUG as an outpatient [exam] prior to completion of the course of antibiotics.
“Patients are discharged when they are afebrile for 24 hours, have adequate oral intake and are able to take oral antibiotics. Please refer to the AAP Clinical Practice Guideline for more detail.5,6
—Michael Fullmer, DO