Short vs Long Intravenous Antibiotic Treatment of Acute Pyelonephritis
Short vs Long Intravenous Antibiotic Treatment of Acute Pyelonephritis
Bouissou F, Munzer C, Decramer S, et al.
Pediatrics. 2008;121:e553-e560
Bouissou and colleagues attempted to determine whether intravenous (IV) antibiotic treatment for acute pyelonephritis was more likely to prevent renal scarring compared to oral treatment.
Investigators compared 2 different treatment courses of antibiotics at 17 French centers. All subjects were treated concurrently with intravenous netilmicin for 2 days and intravenous ceftriaxone for 3 days. They were then divided into groups who received either 5 additional days of oral antibiotic (short IV group) or 5 additional days of intravenous ceftriaxone (long IV group).
The study excluded patients with chronic renal problems, new renal problems diagnosed at the index infection (eg, obstruction or renal malformation), or any previous urinary tract infection. The study also excluded patients who were judged to be severely ill at time of presentation.
Subjects were 3 months to 16 years old. The definition of pyelonephritis included fever, elevated C-reactive protein, dipstick results positive for bacterial nitrite and leukocytes, and at least 100,000 colony-forming units/mL of a known urine pathogen. All patients underwent renal ultrasound at study screening to exclude subjects with malformations, including enlarged kidneys.
Patients underwent voiding cystourethrography at 2-4 weeks after initial presentation, and each underwent nuclear medicine scanning at 6 to 9 months. Any child with grade 4 or 5 reflux at the cystourethrogram evaluation was also not included in the analyses.
The nuclear medicine scan evaluation for the presence of renal scarring at 9 months was the primary outcome of interest. Five hundred forty-eight subjects were randomized (by central investigators) -- 383 children were eligible; 205 patients in the short IV group had complete data vs 178 in the long IV group, a difference that was not statistically significant.
The groups were similar in demographics with the exception of a higher percentage of females in the short IV group (84% vs 78%). A greater percentage of long IV patients had renal scars at the primary outcome point (17% vs 13%), but this difference did not reach statistical significance with a confidence interval (CI) that included 1.0 (odds ratio [OR] 1.45, 95% CI 0.79-2.67). In multivariate analyses, the presence of vesicourethral reflux, especially grade 2 or higher, was associated with renal scarring.
The authors conclude that patients treated with a short course of IV antibiotics followed by oral antibiotics had similar rates of renal scarring after acute pyelonephritis when compared to a group treated entirely intravenously for the same time.
The authors review some of the building data concerning mode (IV vs oral) and duration of treatment for acute pyelonephritis in the introduction and discussion sections of the paper. In general, the literature has been moving practice toward shorter IV therapy and shorter duration of treatment overall, and this study adds nicely to what is known. Should practitioners want to immediately apply this approach, however, it would be worth remembering that this study excluded some very important groups -- children with any previous urinary tract infection, those with any renal malformation or genitourinary malformation, and even children with grade 4 or 5 reflux at the 2- to 4-week cystourethrography study. Given that the decision to treat IV or oral after initial therapy is made before 2-4 weeks, this last exclusion makes it more difficult to directly apply these results to practice unless the clinician knows a patient's reflux status before making the treatment decision.
Abstract
Bouissou F, Munzer C, Decramer S, et al.
Pediatrics. 2008;121:e553-e560
Bouissou and colleagues attempted to determine whether intravenous (IV) antibiotic treatment for acute pyelonephritis was more likely to prevent renal scarring compared to oral treatment.
Investigators compared 2 different treatment courses of antibiotics at 17 French centers. All subjects were treated concurrently with intravenous netilmicin for 2 days and intravenous ceftriaxone for 3 days. They were then divided into groups who received either 5 additional days of oral antibiotic (short IV group) or 5 additional days of intravenous ceftriaxone (long IV group).
The study excluded patients with chronic renal problems, new renal problems diagnosed at the index infection (eg, obstruction or renal malformation), or any previous urinary tract infection. The study also excluded patients who were judged to be severely ill at time of presentation.
Subjects were 3 months to 16 years old. The definition of pyelonephritis included fever, elevated C-reactive protein, dipstick results positive for bacterial nitrite and leukocytes, and at least 100,000 colony-forming units/mL of a known urine pathogen. All patients underwent renal ultrasound at study screening to exclude subjects with malformations, including enlarged kidneys.
Patients underwent voiding cystourethrography at 2-4 weeks after initial presentation, and each underwent nuclear medicine scanning at 6 to 9 months. Any child with grade 4 or 5 reflux at the cystourethrogram evaluation was also not included in the analyses.
The nuclear medicine scan evaluation for the presence of renal scarring at 9 months was the primary outcome of interest. Five hundred forty-eight subjects were randomized (by central investigators) -- 383 children were eligible; 205 patients in the short IV group had complete data vs 178 in the long IV group, a difference that was not statistically significant.
The groups were similar in demographics with the exception of a higher percentage of females in the short IV group (84% vs 78%). A greater percentage of long IV patients had renal scars at the primary outcome point (17% vs 13%), but this difference did not reach statistical significance with a confidence interval (CI) that included 1.0 (odds ratio [OR] 1.45, 95% CI 0.79-2.67). In multivariate analyses, the presence of vesicourethral reflux, especially grade 2 or higher, was associated with renal scarring.
The authors conclude that patients treated with a short course of IV antibiotics followed by oral antibiotics had similar rates of renal scarring after acute pyelonephritis when compared to a group treated entirely intravenously for the same time.
The authors review some of the building data concerning mode (IV vs oral) and duration of treatment for acute pyelonephritis in the introduction and discussion sections of the paper. In general, the literature has been moving practice toward shorter IV therapy and shorter duration of treatment overall, and this study adds nicely to what is known. Should practitioners want to immediately apply this approach, however, it would be worth remembering that this study excluded some very important groups -- children with any previous urinary tract infection, those with any renal malformation or genitourinary malformation, and even children with grade 4 or 5 reflux at the 2- to 4-week cystourethrography study. Given that the decision to treat IV or oral after initial therapy is made before 2-4 weeks, this last exclusion makes it more difficult to directly apply these results to practice unless the clinician knows a patient's reflux status before making the treatment decision.
Abstract