Background: Guidelines for the treatment of acute pyelonephritis in children include parenteral third-generation cephalosporins for at least the initial few days of therapy. A Cochrane review found that seven to 14 days of parenteral therapy was comparable with intravenous therapy for the first three to four days followed by oral antibiotics. The only study of exclusively oral therapy reported that it is comparable with parenteral treatment; however, the generalizability of this study is limited by the young age of participants (average age eight months) and the low number of male participants. Montini and colleagues compared exclusively oral antibiotic therapy with parenteral therapy followed by oral therapy in children with acute pyelonephritis.
The Study: The randomized controlled trial included children one month to six years of age at 28 pediatric units in Italy. Each child had a clinical diagnosis of pyelonephritis that was supported by urinalysis and culture results as well as clinical features such as fever or an elevated neutrophil count, sedimentation rate, or C-reactive protein level. Inclusion criteria were normal prenatal ultrasound findings and no history of acute pyelonephritis. Participants were hospitalized for at least three days or until their temperature returned to normal. Scintigraphy confirmed the location of infection. Children with severe sepsis, dehydration, renal insufficiency, or problems taking the study medications were excluded from the study.
Participants were randomly assigned to receive oral amoxicillin/clavulanate (Augmentin), 50 mg per kg per day for 10 days, or parenteral ceftriaxone (Rocephin), 50 mg per kg per day for the initial three days of therapy; followed by oral amoxicillin/clavulanate for seven days. Blood and urine testing were repeated on the third day of treatment. Treatment could be modified if a child's clinical situation deteriorated during the study. Ultrasonography and scintigraphy were repeated within 10 days of therapy. Renal scanning was repeated after one year to detect scarring in children who had positive scintigraphy results for acute pyelonephritis. The primary end point was renal scarring at 12 months. Secondary end points included time to fever reduction, lower inflammatory indices, or sterile urinalysis.
Results: Although a significant number of children from both treatment groups were lost to follow-up, intention-to-treat analysis showed no significant difference between the groups in renal scarring detected at 12 months (13.7 percent in children who only received oral antibiotics compared with 17.7 percent in children who received parental antibiotics) or in any of the secondary measures. Similarly, subanalysis of children with positive scintigraphy results on entry to the study showed no differences. Fifteen of the 244 children who only received oral antibiotics, and three of the 258 children who received parenteral therapy had minor adverse effects.
Conclusion: The authors conclude that oral antibiotic therapy is as effective as regimens that initially use parenteral agents. Because oral antibiotics are cheaper and easier to administer, hospitalization may be avoided in children with a first febrile urinary tract infection.