Randomised trial of oral versus sequential intravenous/oral cephalosporins in children with pyelonephritis

Abstract

The hypothesis was tested that oral antibiotic treatment in children with acute pyelonephritis and scintigraphy-documented lesions is equally as efficacious as sequential intravenous/oral therapy with respect to the incidence of renal scarring. A randomised multi-centre trial was conducted in 365 children aged 6 months to 16 years with bacterial growth in cultures from urine collected by catheter. The children were assigned to receive either oral ceftibuten (9 mg/kg once daily) for 14 days or intravenous ceftriaxone (50 mg/kg once daily) for 3 days followed by oral ceftibuten for 11 days. Only patients with lesions detected on acute-phase dimercaptosuccinic acid (DMSA) scintigraphy underwent follow-up scintigraphy. Efficacy was evaluated by the rate of renal scarring after 6 months on follow-up scintigraphy. Of 219 children with lesions on acute-phase scintigraphy, 152 completed the study; 80 (72 females, median age 2.2 years) were given ceftibuten and 72 (62 females, median age 1.6 years) were given ceftriaxone/ Eur J Pediatr (2008) ceftibuten. Patients in the intravenous/oral group had significantly higher C-reactive protein (CRP) concentrations at baseline and larger lesion(s) on acute-phase scintigraphy. Follow-up scintigraphy showed renal scarring in 21/80 children treated with ceftibuten and 33/72 with ceftriaxone/ ceftibuten (p=0.01). However, after adjustment for the confounding variables (CRP and size of acute-phase lesion), no significant difference was observed for renal scarring between the two groups (p=0.2). Renal scarring correlated with the extent of the acute-phase lesion (r=0.60, p<0.0001) and the grade of vesico-ureteric reflux (r=0.31, p=0.03), and was more frequent in refluxing renal units (p=0.04). The majority of patients, i.e. 44 in the oral group and 47 in the intravenous/oral group, were managed as out-patients. Side effects were not observed. From this study, we can conclude that once-daily oral ceftibuten for 14 days yielded comparable results to sequential ceftriaxone/ceftibuten treatment in children aged 6 months to 16 years with DMSA-documented acute pyelonephritis and it allowed out-patient management in the majority of these children.

Pattern of Antibiotic Usage in Children Hospitalized for Common Infectious Diseases

“…Only a small fraction, less than 9%, of antibiotic administrations were oral; more than 90% of antibiotic treatments were administered parenterally. As the children included in this study had been hospitalized for treatment of infectious diseases, substantial antibiotic usage was expected; however, experts recommend switching from parenteral to oral medication once the child is stable, or even initiating the treatment with oral antibiotics, especially in children with UTI and pneumonia (9)(10)(11). Overuse of injections leads to numerous adverse effects, including needle stick injuries and transmission of blood-borne infections (12-14).…”

Ceftibuten versus trimethoprim-sulfamethoxazole for oral treatment of febrile urinary tract infection in children

“…There are few controlled treatment trials of acute pyelonephritis in children [1][2][3][4]. This is unfortunate since there are several issues about which we lack basic data.…”

Acute pyelonephritis in children

“…Escherichia coli (E. coli) is the most frequent bacteria, with a prevalence of about 80-90 % [6][7][8]. The primary reservoir of E. coli is the human gut, where this germ is a normal commensal.…”