Clinical efficacy and safety of cefetamet pivoxil in toddlers

Urinary Tract Infection Antibiotic Trial Study Design: A Systematic Review

CONTEXT

Urinary tract infections (UTIs) represent common bacterial infections in children. No guidance on the conduct of pediatric febrile UTI clinical trials (CTs) exist.

OBJECTIVE

To assess the criteria used for patient selection and the efficacy end points in febrile pediatric UTI CTs.

DATA SOURCES

Medline, Embase, Cochrane central databases, and clinicaltrials.gov were searched between January 1, 1990, and November 24, 2016.

STUDY SELECTION

We combined Medical Subject Headings terms and free-text terms for "urinary tract infections" and "therapeutics" and "clinical trials" in children (0-18 years), identifying 3086 articles.

DATA EXTRACTION

Two independent reviewers assessed study quality and performed data extraction.

RESULTS

We included 40 CTs in which a total of 4381 cases of pediatric UTIs were investigated. Positive urine culture results and fever were the most common inclusion criteria (93% and 78%, respectively). Urine sampling method, pyuria, and colony thresholds were highly variable. Clinical and microbiological end points were assessed in 88% and 93% of the studies, respectively. Timing for end point assessment was highly variable, and only 3 studies (17%) out of the 18 performed after the Food and Drug Administration 1998 guidance publication assessed primary and secondary end points consistently with this guidance.

LIMITATIONS

Our limitations included a mixed population of healthy children and children with an underlying condition. In 6 trials, researchers studied a subgroup of patients with afebrile UTI.

CONCLUSIONS

We observed a wide variability in the microbiological inclusion criteria and the timing for end point assessment. The available guidance for adults appear not to be used by pediatricians and do not seem applicable to the childhood UTI. A harmonized design for pediatric UTIs CT is necessary.

Antibiotics for treating lower urinary tract infection in children

BACKGROUND

Urinary tract infection (UTI) is one of the most common bacterial infections in infants and children. Lower UTI is the most commonly presenting and in the majority of cases can be easily treated with a course of antibiotic therapy with no further complications. A number of antimicrobials have been used to treat children with lower UTIs; however is it unclear what are the specific benefits and harms of such treatments.

OBJECTIVES

This review aims to summarise the benefits and harms of antibiotics for treating lower UTI in children.

SEARCH METHODS

We searched the Renal Group's Specialised Register (April 2012), CENTRAL (The Cochrane Library 2012, Issue 5), MEDLINE OVID SP (from 1966), and EMBASE OVID SP (from 1988) without language restriction. Date of last search: May 2012.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs in which antibiotic therapy was used to treat bacteriologically proven, symptomatic, lower UTI in children aged zero to 18 years in primary and community healthcare settings were included.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study quality and extracted data. Statistical analyses were performed using the random effects model and the results expressed as risk ratios (RR) with 95% confidence intervals (CI).

MAIN RESULTS

Sixteen RCTs, analysing 1,116 children were included. Conventional 10-day antibiotic treatment significantly increased the number of children free of persistent bacteriuria compared to single-dose therapy (6 studies, 228 children: RR 2.01, 95%CI 1.06 to 3.80). No heterogeneity was observed. Persistent bacteriuria at the end of treatment was reported in 24% of children receiving single-dose therapy compared to 10% of children who were randomised to 10-day therapy. There were no significant differences between groups for persistent symptoms, recurrence following treatment, or re-infection following treatment. There was insufficient data to analyse the effect of antibiotics on renal parenchymal damage, compliance, development of resistant organisms or adverse events. Despite the inclusion of 16 RCTs, methodological weakness and small sample sizes made it difficult to conclude if any of the included antibiotics or regimens were superior to another.

AUTHORS' CONCLUSIONS

Although antibiotic treatment is effective for children with UTI, there are insufficient data to answer the question of which type of antibiotic or which duration is most effective to treat symptomatic lower UTI. This review found that 10-day antibiotic treatment is more likely to eliminate bacteria from the urine than single-dose treatments. No differences were observed for persistent bacteriuria, recurrence or re-infection between short and long-course antibiotics where the antibiotic differed between groups. This data adds to an existing Cochrane review comparing short and long-course treatment of the same antibiotic who also reported no evidence of difference between short and long-course antibiotics.

Cefetamet pivoxil treatment causes loss of carnitine reserves that can be prevented by exogenous carnitine administration

Two groups of pediatric patients receiving cefetamet pivoxil treatment (3 x 500 mg daily) for 7 days were studied. In the first group (Group A) the drug was administered alone; in the second group (Group B) the drug was given in combination with a molar excess of carnitine (3 x 1 g). Medication with cefetamet pivoxil alone was associated with a large urinary excretion of pivaloylcarnitine: Approximately 71% of the daily pivalate intake could be eliminated as carnitine ester in the urine. In this group, the plasma level and the urinary output of free carnitine decreased. By contrast, in Group B, the administration of molar excess of carnitine aided stochiometric elimination of pivalate as carnitine ester, and the plasma levels and carnitine-free urinary output were unchanged. The data show that medication of cefetamet pivoxil results in the formation of pivaloylcarnitine in children; the sustained loss of carnitine esters can ultimately lead to carnitine deficiency. Molar excess of exogenous carnitine aids in the elimination of pivalate derived from cefetamet pivoxil therapy and helps to maintain the carnitine reserves.

Influence of maturation and growth on cefetamet pivoxil pharmacokinetics: rational dosing for infants

The pharmacokinetics of intravenous (i.v.) cefetamet and the bioavailability of oral cefetamet pivoxil in infants aged 3.5 to 17.3 months who were hospitalized for urological surgery were characterized. The absorption of cefetamet pivoxil administered in a syrup formulation was 38 +/- 19% (n = 5) for infants, which was comparable to values observed for children and adults. The plasma half-life of i.v. cefetamet was 3.03 +/- 0.96 h (mean +/- standard deviation; n = 20) in the infants. This was not different from the value observed for normal adult subjects but was longer than that reported for children aged 3 to 12 years. Urinary recovery of cefetamet after i.v. administration to infants was 63.4 +/- 17.7% (n = 16), which was less than the 80% recovery found in older children and adults. The steady-state volume of distribution was 399 +/- 116 ml/kg of body weight. It was comparable in size and showed the same dependence on body weight as it did in children and adults. The mean systemic clearance per kilogram of body weight in the infants was lower than that in children and adults, apparently because of immaturity of clearance processes. A model that accounted for maturation and growth with increasing age was developed for the clearance. On the basis of this model, the clearance capacity increased from birth to 5 years by a factor of 4.5 because of maturation. Maturation progressed exponentially, with a half-life of 14 months. This model was used to develop dosing regimen guidelines for pediatric patients aged 3.5 months and older.