Oral co-amoxiclav alone effective for first episode of pyelonephritis in children
published 29-08-2007
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A study reported in this week's BMJ found that oral co-amoxiclav was as effective as parenteral ceftriaxone in the treatment of first-episode pyelonephritis in children. The randomized, controlled trial found that children did as well when given the oral antibiotic for the first three days as they did when given ceftriaxone. The accompanying editorial and summary of guidance for diagnosis and management of UTI in children support the strength of the results. The guidelines now suggest treatment with oral antibiotics in children aged 3 months and older with with acute pyelonephritis or upper urinary tract infection. ... continued
The study, carried out in Italy, randomized 502 children from 1 through 6 years with acute pyelonephritis to receive either "Oral co-amoxiclav (50 mg/kg/day in three doses for 10 days) or parenteral ceftriaxone (50 mg/kg/day in a single parenteral dose) for three days, followed by oral co-amoxiclav (50 mg/kg/day in three divided doses for seven days)." The primary outcome was renal scarring, while secondary outcomes were indicators of rapid resolution of illness:
time to defervescence
reduction in inflammatory indices, and
percentage with sterile urine 72 hours after the start of treatment.
There were no significant differences between groups on either primary or secondary outcomes. About ten percent of the children who began on oral antibiotics were switched to parenteral ones because of vomiting or diarrhea (whether or not caused by the co-amoxiclav). About six percent of the bacterial isolates were resistant to co-amoxiclav.
The authors note that the results could allow home treatment of acute pyelonephritis in some cases, but only when close follow-up is assured.
The new guidelines of the British National Institute for Health and Clinical Excellence (NICE) as reported in the summary, include:
Children with a high risk of serious illness2 and/or younger than 3 months:
refer immediately to secondary care
Children aged 3 months and older with acute pyelonephritis or upper urinary tract infection:
consider referral to secondary care
treat with 10 days of oral antibiotics, or if child is unable to tolerate oral antibiotics, start treatment with intravenous antibiotics until oral intake is possible
repeat culture if no response within 24-48 hours
The summary is short, readable and informative, and I think all health workers caring for young children should read it.
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