Should neonates with bacteremic UTI be treated with IV only?

Sleeping newborn boy in the first days of life on white background: © Oksana-stock.adobe.com

Do bacteremic urinary tract infections (UTIs) in neonates have to be treated with IV therapy for the entire duration?

In their session, “Neonates with UTI should be treated with IV therapy only,” Jason Newland, MD, professor of pediatrics, Washington University School of Medicine, Saint Louis, Missouri; and Andrew Haynes, MD, assistant professor, Children’s Hospital Colorado, Aurora put forward the pros and cons of IV therapy and oral therapy (PO) vs IV only, with Newland taking the “pros” side of the argument, and Haynes taking on the “cons.”

UTI is the most common serious bacterial infection in newborns and about 11% of neonates with UTI aged 7 to 28 days had concurrent bacteremia, according to a 2014 study, noted Newland. To support his argument that a switch to oral antibiotics is acceptable, Newland referenced several studies that compared IV and PO and showed no difference in clinical outcomes.

He emphasized that health care practitioners must keep in mind social determinants of health when doing IV therapy only because prolonged hospitalizations come with pressure on the family, decreased parental bonding, peripheral intravenous line (PIV) infiltration, peripherally inserted central catheter (PICC) occlusion, central line infection, etc. Complex outpatient antimicrobial therapy (CoPAT) might be a potential option in the future to address these health inequities.

Haynes, on the other hand, who is studying pharmacokinetics (PK) and pharmacodynamics (PD) for antibiotics in neonates, argues that IV therapy only should be used because 1) there are no guidelines to support PO transition; 2) clinical data referenced by Newland does not completely represent the neonatal population, especially less than 14 to 21 days of life; 3) the pharmacokinetic data is insufficient; and 4) there are many caveats one should keep in mind with PO therapy.

For example, said Haynes, UTI guidelines by the America Academy of Pediatrics omit infants aged less than 2 months, and similarly the febrile infants’ guidelines also look at 8 days to 60 days, hence, there is no clear guidance for neonates less than 8 days.

Continued Haynes, “We also do not have good options of PO therapy in lieu of increasing resistance,” Haynes. Trimethoprim-sulfamethoxazole isn’t favorable in this young population, quinolones lead to chelation with milk, only potential options are amoxicillin – clavulanate and cephalexin. Neonates have delayed absorption and decreased renal clearance with beta-lactams.

Additionally, prior PK/PD studies in neonates and cephalexin are from 1973, said Haynes. In his own research, which is currently underway, Haynes emphasizes how PK/PD in neonates can be very variable.

In summary, in neonates with bacteremic UTIs, the default therapy should not be to switch from IV therapy to PO for all infants (total 7 days) but this would be an acceptable practice in certain low risk scenarios until more neonatal pharmacokinetic and pharmacodynamic data are available. Such low-risk scenarios include: clinical improvement, resolution of fever, patient tolerating PO well, repeat blood culture negative and meningitis excluded. Transition from IV to PO would cut down hospitalization costs and be good for the patient and the family.

Both presenters agreed that more research in addressing equites through complex outpatient antimicrobial therapies (CoPAT) is needed.

Reference
Newland J, Haynes A. Neonates with UTI should be treated with IV therapy only. IDWeek 2023. October 11, 2023. Boston, Massachusetts.