Nonresponders: Prolonged fever among infants with urinary tract infections

Background. The majority of young children with fever and urinary tract inf ections (UTIs) have evidence of pyelonephritis based on renal scans. Resolu tion of fever during treatment is 1 clinical marker of adequate treatment. Theoretically, prolonged fever may be a clue to complications, such as urin ary obstruction or renal abscess. Objective. Describe the pattern of fever in febrile children undergoing tre atment of a UTI. Compare the clinical characteristics of those patients wit h prolonged fever to those who respond faster to therapy. Setting. An urban pediatric hospital. Design. Medical record review. Methods. All children less than or equal to 2 years old admitted to the ped iatric service with a primary discharge diagnosis of pyelonephritis or UTI were reviewed for 65 consecutive months. Patients with previous UTI, known urologic problems, or immunodeficiency were excluded. Only patients with an admitting temperature greater than or equal to 38 degrees C and those who met standard culture criteria were studied. Temperatures are not recorded h ourly on the inpatient unit; therefore, they were assigned to blocks of tim e. Nonresponders were defined as those above the 90th percentile for the ti me to defervesce. Nonresponders were then compared with the balance of the study patients, termed responders. Results. Of 288 patients studied, the median age was 5.6 months (interquart ile range: 1.3-7.9 months old). Median admission temperature was 39.3 degre es C (interquartile range: 38.5 degrees C- 40.1 degrees C). Median time to defervesce ranged in the time block 13 to 16 hours. Sixty-eight percent wer e afebrile by 24 hours and 89% by 48 hours. Thirty-one patients had fever > 48 hours (nonresponders). Nonresponders were older than responders (9.4 vs 4.1 months old) but had similar initial temperatures (39.8 vs 39.2 degrees C), white blood cell counts (18.4 vs 17.1 x 1000/mm(3)), and band counts (1 .4 vs 1.2 x 1000/mm(3)). Nonresponders had similar urinalyses with regard t o leukocyte esterase positive (23/29 vs 211/246), nitrite-positive (8/28 vs 88/221], and the number of patients with "too numerous to count" white blo od cell counts per high power field (12/28 vs 77/220). Nonresponders were a s likely as responders to have bacteremia (3/31 vs 21/256), hydronephrosis by renal ultrasound (1/31 vs 12/232), and significant vesicoureteral reflux (more than or equal to grade 3; 5/26 vs 30/219). Eschericia coli was the p athogen in cultures of 28 of 31 (nonresponders) and 225 of 257 (responders) cultures. The number of cultures with greater than or equal to 100 colony- forming units/mL was similar (25/31 nonresponders vs 206/257 responders). R epeat urine cultures were performed in 93% of patients during the admission ; all culture results were negative. No renal abscesses or pyo-hydronephros is was diagnosed. Conclusions. Eighty-nine percent of young children with febrile UTIs were a febrile within 48 hours of initiating parenteral antibiotics. The patients who took longer than 48 hours to defervesce were clinically similar to thos e whose fevers responded faster to therapy. If antibiotic sensitivities are known, additional diagnostic studies or prolonged hospitalizations may not be justified solely based on persistent fever beyond 48 hours of therapy.