A Systematic Review and Meta-Analysis of the Prevention and Management of Pediatric Urinary Tract Infection and Suspected Urinary Tract Infection: Technical Report.

Abstract

Urinary tract infection (UTI) is a common bacterial infection during childhood. This article reports on a technical review investigating the management of UTI to inform the development of an updated clinical practice guideline (CPG) by the American Academy of Pediatrics (AAP). The authors performed 5 systematic reviews comparing different options for: 1) antibiotic duration in children without known anatomic anomalies; 2) antibiotic route in children without known anatomic anomalies; 3) use of continuous antibiotic prophylaxis (CAP) for children with vesicoureteral reflux (VUR); 4) use of CAP for children with bowel and bladder dysfunction (BBD); and 5) timing of evaluation of children with suspected UTI. We performed database searches of Medline via PubMed, Embase, and Cochrane library from January 1, 2008, through August 5, 2023. Eligible studies were published in English and compared management strategies in a population of children with UTI, suspected UTI, acute pyelonephritis, VUR, and/or BBD. Data on study characteristics and patient-important outcomes were extracted from studies and pooled using meta-analysis when appropriate. Risk of bias was assessed using the Prediction model of Risk Of Bias ASsessment Tool, the Risk of Bias in Nonrandomized Studies of Interventions, and version 2 of the Cochrane risk-of-bias tool for randomized trials. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach. Out of 6154 identified records, a total of 60 studies were included. Overall, there was low to very low certainty regarding the effects of any intervention on patient outcomes. These results suggest that a relatively shorter course of antibiotic therapy (7 days or fewer) may not increase the risk of recurrent UTI, although it is likely to reduce the adverse events associated with antibiotic therapy. Additionally, oral antibiotic therapy may be similarly effective to parenteral (or parenteral-to-oral) therapy while avoiding potential harms associated with hospitalization. Rates of breakthrough UTI and renal scarring may be similar among children who receive CAP compared with those who do not, but rates of antibiotic-resistant UTI may increase with administration of CAP. Prompt medical evaluation within 72 hours of symptom onset may be associated with less renal scarring compared with later evaluation and treatment. These results informed the development of the updated AAP CPG on the management of pediatric UTI, including recommendations on the duration of antibiotic therapy, route of antibiotic administration, use of prophylaxis in children with VUR and BBD, and timing of medical evaluation when UTI is suspected. Specific areas of uncertainty identified through this review may be addressed with future research.