Conclusion: While the data are limited, there does not appear to be a particular serum bicarbonate level that can reliably predict hospital admission in children with acute gastroenteritis.

Question 2: Should prepubescent children with acute epididymitis receive antibiotics?

The majority of studies addressing pediatric epididymitis are retrospective and exclude postpubertal or sexually active children. Therefore, this topic does not address these populations. To begin, let’s look at some representative retrospective studies.

A three-year retrospective study by Sakellaris and Charissis reviewed 66 cases of acute scrotum in preadolescent Greek boys, of which 29 were diagnosed with epididymitis.⁴ Boys with epididymitis were ages 2–13 years and diagnosed with epididymitis via ultrasound (n=28) or intraoperatively (n=1). All patients with acute epididymitis received intravenous antibiotics, and all received follow-up. There were no positive urine cultures and no follow-up complications of testicular atrophy.

Another retrospective study examined 151 cases of first-time epididymitis in children presenting to an outpatient urology clinic.⁵ Ages ranged from 3 months to 17 years. Cases of recurrent epididymitis, recent instrumentation or urologic surgery, or epididymitis secondary to another cause (eg, testicular torsion, vasculitis, hernia, etc.) were excluded. Of note, this study included postpubertal boys. Ninety-seven patients were treated as inpatients. All patients received a scrotal ultrasound (US). Urinalysis (UA) was obtained in 93 of 151 (61.6 percent) patients, and of those 93 patients, there was only one positive urinalysis. The authors describe this case as “mild leukocyturia,” although their definition of mild leukocyturia could not be found. The urine culture was negative in that child. With regard to the remainder of these 93 patients, a urine culture was obtained in only six patients. All patients received antibiotics, but follow-up data are not mentioned. This article suggests that the large majority of epididymitis cases demonstrate negative UA results. Two additional retrospective studies demonstrate similar findings.^6,7 A recent systematic review of 27 retrospective studies by Cristoforo that included 1,496 total pediatric patients also concluded that practitioners “should consider prescribing antibiotics only in the treatment of acute epididymitis for patients with a confirmed bacterial etiology.”⁸

There are two observational prospective studies. The first evaluated prepubertal boys, excluding postpubertal or sexually active patients.⁹ Of the 48 boys included, five (10.4 percent) had a positive UA, defined as > 3 WBC/hpf, or a positive urine culture. All of those with a positive culture had a positive UA. The remaining 43 cases of epididymitis were diagnosed by US only (n=1), radionuclide scan only (n=36), a combination of the two modalities (n=3), or an “experienced clinician” (n=3). Of these 43 remaining cases, 36 (83.7 percent) did not receive antibiotics, and 40 (93 percent) received follow-up. No patients showed any negative effects of epididymitis, with the authors suggesting “antibiotics play little or no role in its management when there are no urinary findings.”