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Ishimori S, Fujimura J, Nakanishi K, Hattori K, Hirase S, Matsunoshita N, Kamiyoshi N, Okizuka Y. Sonographic temporary nephromegaly in children during their first febrile urinary tract infection is a significant prognostic factor for recurrent infection. Sci Rep 2024; 14:19344. [PMID: 39164342 PMCID: PMC11335903 DOI: 10.1038/s41598-024-69588-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 08/06/2024] [Indexed: 08/22/2024] Open
Abstract
There are currently no available data on the relationship between sonographic temporary nephromegaly in children during their first febrile urinary tract infection (fUTI) and recurrent fUTI. For this analysis, a multicenter retrospective cohort study of 343 children who underwent renal ultrasound during their first fUTI was conducted between 2013 and 2020. Sonographic temporary nephromegaly was defined as increased renal length during the initial fUTI, followed by normal renal length after antibiotic treatment. Compared with children without sonographic temporary nephromegaly (n = 307), the duration of fever and intravenous antibiotics was significantly longer, and C-reactive protein, creatinine, and the proportion of children who had recurrent fUTI were significantly higher, in those with sonographic temporary nephromegaly (n = 36). In an additional analysis of 100 patients who received voiding cystourethrography, a logistic regression model confirmed that the odds of vesicoureteral reflux (VUR) were significantly higher in children with temporary nephromegaly or those who experienced fUTI recurrence. In nine out of 16 children with VUR who had temporary nephromegaly, the reason for receiving voiding cystourethrography was recurrent fUTI. Our results suggest that sonographic temporary nephromegaly during an initial fUTI is predictive for recurrence and VUR, and that in children with temporary nephromegaly, VUR may be detectable before fUTI recurrence.
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Affiliation(s)
- Shingo Ishimori
- Department of Pediatrics, Takatsuki General Hospital, 1-3-13 Kosobe-Cho, Takatsuki, Osaka, 569-1192, Japan.
| | - Junya Fujimura
- Department of Pediatrics, Kakogawa Central City Hospital, Kakogawa, Hyogo, Japan
| | - Keita Nakanishi
- Department of Pediatrics, Saiseikai-Hyogo Hospital, Kobe, Hyogo, Japan
| | - Kengo Hattori
- Department of Pediatric Surgery, Takatsuki General Hospital, Takatsuki, Osaka, Japan
| | - Satoshi Hirase
- Department of Pediatrics, Konan Medical Center, Kobe, Hyogo, Japan
| | | | - Naohiro Kamiyoshi
- Department of Pediatrics, Himeji Red Cross Hospital, Himeji, Hyogo, Japan
| | - Yo Okizuka
- Department of Pediatrics, Takatsuki General Hospital, 1-3-13 Kosobe-Cho, Takatsuki, Osaka, 569-1192, Japan
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Vazouras K, Jackson C, Folgori L, Anastasiou-Katsiardani A, Hsia Y, Basmaci R. Quality indicators for appropriate antibiotic prescribing in urinary tract infections in children. BMC Infect Dis 2023; 23:400. [PMID: 37308821 DOI: 10.1186/s12879-023-08356-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 05/29/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND The aim of this study was to define a set of urinary tract infections (UTIs)-specific quality indicators for appropriate prescribing in children and evaluate clinical practices in a district general hospital in Greece. METHODS The UTIs-specific quality indicators were informed by a review of the existing literature. Quality indicators were selected to describe the overall antibiotics use, prescribing patterns and UTIs clinical management regarding treatment and prophylaxis in a cohort of children admitted with a UTI. Microbiological, clinical and prescribing data about dosing, duration and route of administration were collected from the patients' electronic health records. RESULTS Twelve quality indicators were adapted or developed for prescribing in childhood UTIs. A broad variety of antibiotics were prescribed for UTIs, with a drug utilization (DU) 90% rate of 6 and 9 different antibiotics for febrile and afebrile UTIs, respectively. Despite the low incidence of multi-drug resistant UTIs in the study period (9/261, 3.4%), broad-spectrum antibiotics were prescribed in 33.5% (164/490) of prescriptions. A total of 62.8% (164/261) of patients were started on empiric combined therapies, while opportunities to de-escalate were missed in 37.8% (62/164) of them. One quarter (67/261, 25.7%) of patients did not fulfil the criteria for receiving treatment, while nearly half of those prescribed prophylaxis (82/175, 46.9%) could have avoided having a prophylaxis prescription. CONCLUSIONS Our study identified substantial gaps for improvement in antimicrobial prescribing for UTIs in children. The application of the proposed quality indicators could help to limit unnecessary antibiotics use in children with UTI.
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Affiliation(s)
- Konstantinos Vazouras
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle Upon Tyne Hospital NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Charlotte Jackson
- Paediatric Infectious Diseases Research Group, Institute of Infection and Immunity, St George's University of London, Cranmer Terrace, London, SW17 0QT, England
| | - Laura Folgori
- Paediatric Infectious Disease Unit, Department of Paediatrics, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | | | - Yingfen Hsia
- Paediatric Infectious Diseases Research Group, Institute of Infection and Immunity, St George's University of London, Cranmer Terrace, London, SW17 0QT, England.
- Queen's University Belfast, School of Pharmacy, 97 Lisburn Road, Belfast, BT9 7BL, UK.
| | - Romain Basmaci
- Service de Pédiatrie-Urgences, Hôpital Louis-Mourier, Assistance Publique - Hôpitaux de Paris, 92700, Colombes, France
- Université de Paris, Infection, Antimicrobiens, Modélisation, Evolution, Unité Mixte de Recherche 1137, Institut National de La Santé Et de La Recherche Médicale, 75006, Paris, France
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Shaikh KJ, Osio VA, Leeflang MM, Shaikh N. Procalcitonin, C-reactive protein, and erythrocyte sedimentation rate for the diagnosis of acute pyelonephritis in children. Cochrane Database Syst Rev 2020; 9:CD009185. [PMID: 32911567 PMCID: PMC8479592 DOI: 10.1002/14651858.cd009185.pub3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND In children with urinary tract infection (UTI), only those with pyelonephritis (and not cystitis) are at risk for developing long-term renal sequelae. If non-invasive biomarkers could accurately differentiate children with cystitis from children with pyelonephritis, treatment and follow-up could potentially be individualized. This is an update of a review first published in 2015. OBJECTIVES The objectives of this review were to 1) determine whether procalcitonin (PCT), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) can replace the acute DMSA scan in the diagnostic evaluation of children with UTI; 2) assess the influence of patient and study characteristics on the diagnostic accuracy of these tests, and 3) compare the performance of the three tests to each other. SEARCH METHODS We searched MEDLINE, EMBASE, DARE, Web of Science, and BIOSIS Previews through to 17th December 2019 for this review. The reference lists of all included articles and relevant systematic reviews were searched to identify additional studies not found through the electronic search. SELECTION CRITERIA We only considered published studies that evaluated the results of an index test (PCT, CRP, ESR) against the results of an acute-phase 99Tc-dimercaptosuccinic acid (DMSA) scan (conducted within 30 days of the UTI) in children aged 0 to 18 years with a culture-confirmed episode of UTI. The following cut-off values were used for the primary analysis: 0.5 ng/mL for procalcitonin, 20 mg/L for CRP and 30 mm/hour for ESR. DATA COLLECTION AND ANALYSIS Two authors independently applied the selection criteria to all citations and independently abstracted data. We used the bivariate model to calculate pooled random-effects pooled sensitivity and specificity values. MAIN RESULTS A total of 36 studies met our inclusion criteria. Twenty-five studies provided data for the primary analysis: 12 studies (1000 children) included data on PCT, 16 studies (1895 children) included data on CRP, and eight studies (1910 children) included data on ESR (some studies had data on more than one test). The summary sensitivity estimates (95% CI) for the PCT, CRP, ESR tests at the aforementioned cut-offs were 0.81 (0.67 to 0.90), 0.93 (0.86 to 0.96), and 0.83 (0.71 to 0.91), respectively. The summary specificity values for PCT, CRP, and ESR tests at these cut-offs were 0.76 (0.66 to 0.84), 0.37 (0.24 to 0.53), and 0.57 (0.41 to 0.72), respectively. AUTHORS' CONCLUSIONS The ESR test does not appear to be sufficiently accurate to be helpful in differentiating children with cystitis from children with pyelonephritis. A low CRP value (< 20 mg/L) appears to be somewhat useful in ruling out pyelonephritis (decreasing the probability of pyelonephritis to < 20%), but unexplained heterogeneity in the data prevents us from making recommendations at this time. The procalcitonin test seems better suited for ruling in pyelonephritis, but the limited number of studies and the marked heterogeneity between studies prevents us from reaching definitive conclusions. Thus, at present, we do not find any compelling evidence to recommend the routine use of any of these tests in clinical practice.
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Affiliation(s)
- Kai J Shaikh
- Department of Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Victor A Osio
- Department of General Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Mariska Mg Leeflang
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Nader Shaikh
- General Academic Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
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Chang PW, Wang ME, Schroeder AR. Diagnosis and Management of UTI in Febrile Infants Age 0-2 Months: Applicability of the AAP Guideline. J Hosp Med 2020; 15:e1-e5. [PMID: 32118563 DOI: 10.12788/jhm.3349] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 10/30/2019] [Indexed: 11/20/2022]
Abstract
Urinary tract infections (UTIs) are the most common bacterial infection in young infants. The American Academy of Pediatrics' (AAP) clinical practice guideline for UTIs focuses on febrile children age 2-24 months, with no guideline for infants <2 months of age, an age group commonly encountered by pediatric hospitalists. In this review, we assess the applicability of the AAP UTI Guideline's action statements for previously healthy, febrile infants <2 months of age. We also discuss additional considerations in this age group, including concurrent bacteremia and routine testing for meningitis.
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Affiliation(s)
- Pearl W Chang
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Marie E Wang
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Alan R Schroeder
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
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Raupach T, Held J, Prokosch HU, Rascher W, Zierk J. Resistance to antibacterial therapy in pediatric febrile urinary tract infections-a single-center analysis. J Pediatr Urol 2020; 16:71-79. [PMID: 31740148 DOI: 10.1016/j.jpurol.2019.10.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Accepted: 10/18/2019] [Indexed: 01/23/2023]
Abstract
BACKGROUND Febrile urinary tract infections (UTIs) are common serious bacterial infections in childhood and require early diagnosis and antibacterial therapy. However, considerable uncertainty exists regarding the optimal antibacterial agent for primary treatment of pediatric UTIs. Additionally, patterns of susceptibility and resistance change over time and microbiological in vitro resistance is not necessarily associated with treatment failure. Here, we analyzed uropathogens, their resistance patterns, and response to antibacterial treatment in children with acute pyelonephritis. METHODS We used billing codes (international classification of diseases) to identify all inpatients aged 0-18 years with febrile UTIs in a German university tertiary care center from 2009 until 2018. Microbial results were retrieved from the laboratory information system for all children, and treatment regimen and treatment response were analyzed in a subgroup of children. RESULTS We identified 907 children with acute pyelonephritis; in 590 cases (65%) an uropathogen was detected. Escherichia coli (60.8%), Enterococcus faecalis (13.2%), Klebsiella pneumoniae (7.0%), Proteus spp. (5.2%), and Pseudomonas aeruginosa (4.2%) were the most common pathogens. 353 of 436 E.coli isolates (81.0%) were susceptible or intermediate to aminopenicillin/β-lactamase-inhibitor (BLI) combinations. We examined 52 cases where E. coli was resistant to initial therapy with aminopenicillin/BLI combinations: Therapy was changed in 35 cases (67%) and left unchanged in 17 cases (33%), and we found no significant differences in C-reactive protein and leucocyte count in blood and urine between both groups after 3 days. CONCLUSIONS We present the spectrum of uropathogens and susceptibility test results in pediatric UTIs in a tertiary care center. Our findings suggest a satisfactory response to first-line therapy with aminopenicillin/BLI combinations.
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Affiliation(s)
- Thomas Raupach
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Erlangen, Germany
| | - Jürgen Held
- Mikrobiologisches Institut-Klinische Mikrobiologie, Immunologie und Hygiene, Universitätsklinikum Erlangen und Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Hans-Ulrich Prokosch
- Chair of Medical Informatics, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Wolfgang Rascher
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Erlangen, Germany
| | - Jakob Zierk
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Erlangen, Germany; Center of Medical Information and Communication Technology, University Hospital Erlangen, Erlangen, Germany.
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Vitamin A supplementation is effective for improving the clinical symptoms of urinary tract infections and reducing renal scarring in girls with acute pyelonephritis: a randomized, double-blind placebo-controlled, clinical trial study. Complement Ther Med 2019; 42:429-437. [DOI: 10.1016/j.ctim.2018.12.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Revised: 12/09/2018] [Accepted: 12/10/2018] [Indexed: 01/24/2023] Open
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Simrén Y, Valdimarsson S, Stokland E, Lagerstrand KM, Sixt R, Hansson S. Renal swelling indicates renal damage in infants with their first urinary tract infection. Acta Paediatr 2018; 107:2004-2010. [PMID: 29972698 DOI: 10.1111/apa.14489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 05/21/2018] [Accepted: 07/02/2018] [Indexed: 11/29/2022]
Abstract
AIM We used ultrasound to evaluate renal swelling as a predictor of acute and permanent renal damage in infants with their first urinary tract infection (UTI). METHODS The cohort at the Queen Silvia Children's Hospital, Gothenburg, Sweden, comprised 101 infants with their first UTI at a mean age of 3.9 ± 3.0 months. Acute and follow-up ultrasounds were carried out a few days and one month after treatment started, and a 99m technetium dimercaptosuccinic acid (DMSA) scan was carried out after one month and after a year if the first scan was abnormal. RESULTS The acute ultrasounds showed that renal length and volume, calculated as standard deviation scores (SDS), were 1.39 ± 1.43 SDS and 1.30 ± 1.08 SDS. We found that 52% of the one-month DMSA scans and 25% of the one-year DMSA scans were abnormal. Renal length (p = 0.0026) and initial volume (p = 0.0005) on the ultrasound predicted acute renal damage at the one-month DMSA scan and initial renal length (p = 0.030) predicted permanent renal damage at the one-year DMSA scan. CONCLUSION Renal swelling was associated with renal damage. Although the diagnostic performance compared with the DMSA scan was weak, renal swelling may help clinicians to make decisions about further investigations and follow-ups of infants with UTIs.
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Affiliation(s)
- Y Simrén
- Department of Radiology; Institute of Clinical Sciences at Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - S Valdimarsson
- Department of Paediatrics; Institute of Clinical Sciences at Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - E Stokland
- Department of Radiology; Institute of Clinical Sciences at Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - K M Lagerstrand
- Department of Radiation Physics; Institute of Clinical Sciences at Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - R Sixt
- Department of Paediatric Clinical Physiology; Institute of Clinical Sciences at Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - S Hansson
- Department of Paediatrics; Institute of Clinical Sciences at Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
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Joshi NS, Lucas BP, Schroeder AR. Physician Preferences Surrounding Urinary Tract Infection Management in Neonates. Hosp Pediatr 2017; 8:21-27. [PMID: 29196453 DOI: 10.1542/hpeds.2017-0082] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Variability exists in the treatment of neonates with urinary tract infection (UTI), potentially reflecting an overuse of resources. A cross-sectional vignette survey was designed to examine variability in physician preferences for intravenous (IV) antibiotic duration, genitourinary imaging, and prophylactic antibiotics and to evaluate drivers of resource use. METHODS The survey was administered to a random sample of pediatricians through the American Medical Association's Physician Masterfile. Respondents were provided with a case vignette of a 2-week-old neonate with a febrile UTI and asked to indicate preferences for IV antibiotic duration and rank drivers of this decision. Respondents were also asked whether they would obtain a voiding cystourethrogram (VCUG) and, regardless of preference, randomly presented with a normal result or bilateral grade II vesicoureteral reflux. The survey was delivered electronically to facilitate skip logic and randomization. RESULTS A total of 279 surveys were completed. Preference for total IV antibiotic duration differed significantly (P < .001) across specialty, with a median duration of 2 days for general pediatricians/hospitalists, 7 days for neonatologists, and 5 days for infectious disease pediatricians. For the 47% (n = 131) who did not want a VCUG, 24/61 (39%) wanted prophylactic antibiotics when presented with grade II vesicoureteral reflux (P < .001). CONCLUSIONS Subspecialty status appeared to be the most influential driver of IV antibiotic duration in the treatment of UTI. A substantial proportion of pediatricians who initially expressed a preference against ordering a VCUG wished to prescribe prophylactic antibiotics when results were abnormal, which suggests that even unwanted diagnostic test results drive treatment decisions.
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Affiliation(s)
- Neha S Joshi
- Department of Pediatrics, School of Medicine, Stanford University, Palo Alto, California;
| | - Brian P Lucas
- White River Junction Veteran's Affairs Medical Center, Hartford, Vermont; and.,Department of Medicine, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Alan R Schroeder
- Department of Pediatrics, School of Medicine, Stanford University, Palo Alto, California
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Beetz R. Pyelonephritis und Urosepsis. Monatsschr Kinderheilkd 2017. [DOI: 10.1007/s00112-017-0402-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Simrén Y, Stokland E, Lagerstrand KM, Valdimarsson S, Hansson S. Ultrasound is an effective and noninvasive method of evaluating renal swelling in infants with their first urinary tract infection. Acta Paediatr 2017; 106:1868-1874. [PMID: 28349603 DOI: 10.1111/apa.13849] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 03/21/2017] [Accepted: 03/24/2017] [Indexed: 11/27/2022]
Abstract
AIM This study evaluated renal swelling in infants with a first urinary tract infection (UTI) by correlating renal length and volume with C-reactive protein (CRP) and body temperature. METHODS Ultrasounds were carried out on 104 infants at The Queen Silvia Children's Hospital, Gothenburg, Sweden - 58 boys (mean age 3.3 months) and 46 girls (mean age 4.8 months) - during the acute phase of their UTI. A second scan was performed on 94 of them 4 weeks later. Renal length and volume were computed to standard deviation scores (SDS). RESULTS The mean renal length and volume at the first ultrasound were 1.90 SDS (±1.54) and 1.67 SDS (±1.13) for the larger kidney and 0.86 SDS (±1.01) and 0.84 SDS (±0.90) for the smaller kidney. There was a significant decrease in renal length and volume between the two ultrasounds, with a mean difference of 0.96 SDS (±1.24) and 1.07 SDS (±1.10) for the larger kidney (p < 0.0001). The length and volume of the larger kidney correlated with CRP (p < 0.001), but only the renal length correlated with fever (p < 0.001). CONCLUSION Early ultrasound determined renal swelling in infants with a UTI and may be a valuable noninvasive way of identifying infants with renal parenchymal involvement.
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Affiliation(s)
- Y Simrén
- Department of Radiology, Institute of Clinical Sciences at Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - E Stokland
- Department of Radiology, Institute of Clinical Sciences at Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - K M Lagerstrand
- Department of Radiation Physics, Institute of Clinical Sciences at Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - S Valdimarsson
- Department of Paediatrics; Institute of Clinical Sciences at Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - S Hansson
- Department of Paediatrics; Institute of Clinical Sciences at Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
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Lepage P, Blumental S. Specialty Grand Challenge In Pediatric Infectious Diseases. Front Pediatr 2017; 5:185. [PMID: 28894730 PMCID: PMC5581326 DOI: 10.3389/fped.2017.00185] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 08/14/2017] [Indexed: 01/16/2023] Open
Affiliation(s)
- Philippe Lepage
- Hôpital Universitaire des Enfants Reine Fabiola, Brussels, Belgium.,Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Sophie Blumental
- Hôpital Universitaire des Enfants Reine Fabiola, Brussels, Belgium.,Université Libre de Bruxelles (ULB), Brussels, Belgium
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Folgori L, Bielicki J, Ruiz B, Turner MA, Bradley JS, Benjamin DK, Zaoutis TE, Lutsar I, Giaquinto C, Rossi P, Sharland M. Harmonisation in study design and outcomes in paediatric antibiotic clinical trials: a systematic review. THE LANCET. INFECTIOUS DISEASES 2016; 16:e178-e189. [PMID: 27375212 DOI: 10.1016/s1473-3099(16)00069-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 01/15/2016] [Accepted: 01/28/2016] [Indexed: 10/21/2022]
Abstract
There is no global consensus on the conduct of clinical trials in children and neonates with complicated clinical infection syndromes. No comprehensive regulatory guidance exists for the design of antibiotic clinical trials in neonates and children. We did a systematic review of antibiotic clinical trials in complicated clinical infection syndromes (including bloodstream infections and community-acquired pneumonia) in children and neonates (0-18 years) to assess whether standardised European Medicines Agency (EMA) and US Food and Drug Administration (FDA) guidance for adults was used in paediatrics, and whether paediatric clinical trials applied consistent definitions for eligibility and outcomes. We searched MEDLINE, Cochrane CENTRAL databases, and ClinicalTrials.gov between Jan 1, 2000, and Nov 18, 2015. 82 individual studies met our inclusion criteria. The published studies reported on an average of 66% of CONSORT items. Study design, inclusion and exclusion criteria, and endpoints varied substantially across included studies. The comparison between paediatric clinical trials and adult EMA and FDA guidance highlighted that regulatory definitions are only variably applicable and used at present. Absence of consensus for paediatric antibiotic clinical trials is a major barrier to harmonisation in research and translation into clinical practice. To improve comparison of therapies and strategies, international collaboration among all relevant stakeholders leading to harmonised case definitions and outcome measures is needed.
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Affiliation(s)
- Laura Folgori
- Paediatric Infectious Disease Research Group, Institute for Infection and Immunity, St George's University of London, London, UK
| | - Julia Bielicki
- Paediatric Infectious Disease Research Group, Institute for Infection and Immunity, St George's University of London, London, UK; Paediatric Pharmacology, University Children's Hospital Basel, Basel, Switzerland
| | - Beatriz Ruiz
- Paediatric Infectious Disease Research Group, Institute for Infection and Immunity, St George's University of London, London, UK
| | - Mark A Turner
- University of Liverpool, Institute of Translational Medicine, Department of Women's and Children's Health, Crown Street, Liverpool, UK
| | - John S Bradley
- Department of Pediatrics, University of California San Diego, San Diego, CA, USA; Rady Children's Hospital San Diego, San Diego, CA, USA
| | | | - Theoklis E Zaoutis
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA; Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Irja Lutsar
- Institute of Medical Microbiology, University of Tartu, Tartu, Estonia
| | - Carlo Giaquinto
- Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Paolo Rossi
- University Department of Pediatrics (DPUO), Bambino Gesù Children's Hospital, Rome, Italy
| | - Mike Sharland
- Paediatric Infectious Disease Research Group, Institute for Infection and Immunity, St George's University of London, London, UK.
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Schroeder AR, Shen MW, Biondi EA, Bendel-Stenzel M, Chen CN, French J, Lee V, Evans RC, Jerardi KE, Mischler M, Wood KE, Chang PW, Roman HK, Greenhow TL. Bacteraemic urinary tract infection: management and outcomes in young infants. Arch Dis Child 2016; 101:125-30. [PMID: 26177657 DOI: 10.1136/archdischild-2014-307997] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 06/24/2015] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To determine predictors of parenteral antibiotic duration and the association between parenteral treatment duration and relapses in infants <3 months with bacteraemic urinary tract infection (UTI). DESIGN Multicentre retrospective cohort study. SETTING Eleven healthcare institutions across the USA. PATIENTS Infants <3 months of age with bacteraemic UTI, defined as the same pathogenic organism isolated from blood and urine. MAIN OUTCOME MEASURES Duration of parenteral antibiotic therapy, relapsed UTI within 30 days. RESULTS The mean (±SD) duration of parenteral antibiotics for the 251 included infants was 7.8 days (±4 days), with considerable variability between institutions (mean range 5.5-12 days). Independent predictors of the duration of parenteral antibiotic therapy included (coefficient, 95% CI): age (-0.2 days, -0.3 days to -0.08 days, for each week older), year treated (-0.2 days, -0.4 to -0.03 days for each subsequent calendar year), male gender (0.9 days, 0.01 to 1.8 days), a positive repeat blood culture during acute treatment (3.5 days, 1.2-5.9 days) and a non-Escherichia coli organism (2.2 days, 0.8-3.6 days). No infants had a relapsed bacteraemic UTI. Six infants (2.4%) had a relapsed UTI (without bacteraemia). The duration of parenteral antibiotics did not differ between infants with and without a relapse (8.2 vs 7.8 days, p=0.81). CONCLUSIONS Parenteral antibiotic treatment duration in young infants with bacteraemic UTI was variable and only minimally explained by measurable patient factors. Relapses were rare and were not associated with treatment duration. Shorter parenteral courses may be appropriate in some infants.
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Affiliation(s)
- Alan R Schroeder
- Department of Pediatrics, Santa Clara Valley Medical Center, San Jose, California, USA Stanford University School of Medicine, Stanford, California, USA
| | - Mark W Shen
- Department of Pediatrics, Dell Children's Medical Center, Austin, Texas, USA
| | - Eric A Biondi
- Department of Pediatrics, University of Rochester, Rochester, New York, USA
| | - Michael Bendel-Stenzel
- Department of Pediatrics, Children's Hospital and Clinics of Minnesota, Minneapolis, Minnesota, USA
| | - Clifford N Chen
- Department of Pediatrics, University of Texas Southwestern, Dallas, Texas, USA
| | - Jason French
- Department of Pediatrics, Children's Hospital Colorado, Denver, Colorado, USA
| | - Vivian Lee
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Rianna C Evans
- Department of Pediatrics, Children's Hospital of the King's Daughters, Norfolk, Virginia, USA
| | - Karen E Jerardi
- Department of Pediatrics, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Matt Mischler
- Department of Pediatrics, Children's Hospital of Illinois, Peoria, Illinois, USA
| | - Kelly E Wood
- Department of Pediatrics, University of Iowa Children's Hospital, Iowa City, Iowa, USA
| | - Pearl W Chang
- Department of Pediatrics, Santa Clara Valley Medical Center, San Jose, California, USA Stanford University School of Medicine, Stanford, California, USA Department of Pediatrics, Kaiser Permanente Northern California, San Francisco, California, USA
| | - Heidi K Roman
- Department of Pediatrics, Santa Clara Valley Medical Center, San Jose, California, USA Stanford University School of Medicine, Stanford, California, USA Department of Pediatrics, University of Texas Southwestern, Dallas, Texas, USA
| | - Tara L Greenhow
- Department of Pediatrics, Kaiser Permanente Northern California, San Francisco, California, USA
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Shaikh N, Borrell JL, Evron J, Leeflang MMG. Procalcitonin, C-reactive protein, and erythrocyte sedimentation rate for the diagnosis of acute pyelonephritis in children. Cochrane Database Syst Rev 2015; 1:CD009185. [PMID: 25603480 PMCID: PMC7104675 DOI: 10.1002/14651858.cd009185.pub2] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND In children with urinary tract infection (UTI), only those with pyelonephritis (and not cystitis) are at risk for developing long-term renal sequelae. If non-invasive biomarkers could accurately differentiate children with cystitis from children with pyelonephritis, treatment and follow-up could potentially be individualized. OBJECTIVES The objectives of this review were to 1) determine whether procalcitonin, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) can replace the acute DMSA scan in the diagnostic evaluation of children with UTI; 2) assess the influence of patient and study characteristics on the diagnostic accuracy of these tests, and 3) compare the performance of the three tests to each other. SEARCH METHODS We searched MEDLINE, EMBASE, DARE, Web of Science, and BIOSIS Previews for this review. The reference lists of all included articles and relevant systematic reviews were searched to identify additional studies not found through the electronic search. SELECTION CRITERIA We only considered published studies that evaluated the results of an index test (procalcitonin, CRP, ESR) against the results of an acute-phase DMSA scan (conducted within 30 days of the UTI) in children aged 0 to 18 years with a culture-confirmed episode of UTI. The following cutoff values were used for the primary analysis: 0.5 ng/mL for procalcitonin, 20 mg/L for CRP and 30 mm/h for ESR. DATA COLLECTION AND ANALYSIS Two authors independently applied the selection criteria to all citations and independently abstracted data. We used the bivariate model to calculate pooled random-effects pooled sensitivity and specificity values. MAIN RESULTS A total of 24 studies met our inclusion criteria. Seventeen studies provided data for the primary analysis: six studies (434 children) included data on procalcitonin, 13 studies (1638 children) included data on CRP, and six studies (1737 children) included data on ESR (some studies had data on more than one test). The summary sensitivity estimates (95% CI) for the procalcitonin, CRP, ESR tests at the aforementioned cutoffs were 0.86 (0.72 to 0.93), 0.94 (0.85 to 0.97), and 0.87 (0.77 to 0.93), respectively. The summary specificity values for procalcitonin, CRP, and ESR tests at these cutoffs were 0.74 (0.55 to 0.87), 0.39 (0.23 to 0.58), and 0.48 (0.33 to 0.64), respectively. AUTHORS' CONCLUSIONS The ESR test does not appear to be sufficiently accurate to be helpful in differentiating children with cystitis from children with pyelonephritis. A low CRP value (< 20 mg/L) appears to be somewhat useful in ruling out pyelonephritis (decreasing the probability of pyelonephritis to < 20%), but unexplained heterogeneity in the data prevents us from making recommendations at this time. The procalcitonin test seems better suited for ruling in pyelonephritis, but the limited number of studies and the marked heterogeneity between studies prevents us from reaching definitive conclusions. Thus, at present, we do not find any compelling evidence to recommend the routine use of any of these tests in clinical practice.
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Affiliation(s)
- Nader Shaikh
- Children's Hospital of PittsburghGeneral Academic Pediatrics3414 Fifth Ave, Suite 301PittsburghPAUSA15213
| | - Jessica L Borrell
- Warren Alpert Medical School of Brown University222 Richmond StProvidenceRIUSA02903
| | - Josh Evron
- Tulane University School of Medicine1808 Robert StNew OrleansLAUSA70115
| | - Mariska MG Leeflang
- Academic Medical Center, J1B‐207‐1Department of Clinical Epidemiology and BiostatisticsP.O. Box 22700AMSTERDAMNetherlands1100 DE
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Awais M, Rehman A, Baloch NUA, Khan F, Khan N. Evaluation and management of recurrent urinary tract infections in children: state of the art. Expert Rev Anti Infect Ther 2014; 13:209-31. [PMID: 25488064 DOI: 10.1586/14787210.2015.991717] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Urinary tract infections (UTIs) represent an important cause of febrile illness in young children and can lead to renal scarring and kidney failure. However, diagnosis and treatment of recurrent UTI in children is an area of some controversy. Guidelines from the American Academy of Pediatrics, National Institute for Health and Clinical Excellence and European Society of Paediatric Radiology differ from each other in terms of the diagnostic algorithm to be followed. Treatment of vesicoureteral reflux and antibiotic prophylaxis for prevention of recurrent UTI are also areas of considerable debate. In this review, we collate and appraise recently published literature in order to formulate evidence-based guidance for the diagnosis and treatment of recurrent UTI in children.
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Affiliation(s)
- Muhammad Awais
- Department of Radiology, Aga Khan University Hospital, P.O. box 3500, Stadium Road, Karachi 74800, Sindh, Pakistan
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McDonald K, Kenney I. Paediatric urinary tract infections: a retrospective application of the National Institute of Clinical Excellence guidelines to a large general practitioner referred historical cohort. Pediatr Radiol 2014; 44:1085-92. [PMID: 24789768 DOI: 10.1007/s00247-014-2967-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Revised: 12/21/2013] [Accepted: 03/05/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND The National Institute for Clinical Excellence (NICE) is a United Kingdom nondepartmental public body accountable to the Department of Health. Before the introduction of the NICE guidelines in the United Kingdom most children younger than 1 year of age had a urinary tract ultrasound, cyclic micturating cystourethrogram and dimercaptosuccinic acid scintigraphy, the latter delayed 6 months post infection. Children older than 1 year had a urinary tract ultrasound only, and further imaging if necessary. OBJECTIVE Identify who would have been investigated had the NICE imaging strategy been used and who would not. Compare the diagnostic yield and patient outcome with the previous imaging protocol using our prospectively collected historical data. MATERIALS AND METHODS We applied the new imaging strategy to a historic cohort of 934 patients with a urinary tract infection (UTI) referred by general practitioners to a specialist children's hospital between 1996 and 2002. RESULTS Of the 934 patients referred, 218 would have been investigated according to the NICE guidelines. In total, there were 105 patients with abnormal imaging findings, and 44 of these (42%) would have been investigated under the NICE guidelines. CONCLUSION Applying the NICE guidelines to children presenting with UTI will reduce the number imaged by 77% and will lead to missed identification of 58% of imaging abnormalities in the group. The majority of these abnormalities may be important. While supporting conservative investigation protocols, we are concerned that many abnormalities might go undetected.
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Affiliation(s)
- Kirsteen McDonald
- Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, E1 1BB, UK,
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18
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Schroeder AR, Ralston SL. Intravenous antibiotic durations for common bacterial infections in children: when is enough enough? J Hosp Med 2014; 9:604-9. [PMID: 25044445 DOI: 10.1002/jhm.2239] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 06/23/2014] [Accepted: 07/07/2014] [Indexed: 11/11/2022]
Abstract
Durations of intravenous antibiotic therapy for bacterial infections in hospitalized children sometimes extend well beyond clinical recovery and are often the primary determinants of length of stay. These durations, however, are not always based on solid evidence. Moreover, fixed durations are invariant to important individual factors. We review guidelines and the available evidence for durations of intravenous antibiotic therapy for meningitis, bacteremia, urinary tract infection, and osteomyelitis, conditions where intravenous antibiotics often extend beyond resolution of clinical symptoms. We propose a framework for the duration of therapy that is intended to serve as a guide when standards of care are either nonexistent, dated, conflicting, or contrary to evidence from published studies. This framework incorporates patient-centered factors such as severity of infection, response to therapy, ease of intravenous access, harms and costs of ongoing intravenous treatment, and family preferences.
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Affiliation(s)
- Alan R Schroeder
- Department of Pediatrics, Santa Clara Valley Medical Center, San Jose, California
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19
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Strohmeier Y, Hodson EM, Willis NS, Webster AC, Craig JC. Antibiotics for acute pyelonephritis in children. Cochrane Database Syst Rev 2014; 2014:CD003772. [PMID: 25066627 PMCID: PMC10580126 DOI: 10.1002/14651858.cd003772.pub4] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Urinary tract infection (UTI) is one of the most common bacterial infections in infants. The most severe form of UTI is acute pyelonephritis, which results in significant acute morbidity and may cause permanent kidney damage. There remains uncertainty regarding the optimum antibiotic regimen, route of administration and duration of treatment. This is an update of a review that was first published in 2003 and updated in 2005 and 2007. OBJECTIVES To evaluate the benefits and harms of antibiotics used to treat children with acute pyelonephritis. The aspects of therapy considered were 1) different antibiotics, 2) different dosing regimens of the same antibiotic, 3) different duration of treatment, and 4) different routes of administration. SEARCH METHODS We searched the Cochrane Renal Group's Specialised Register, CENTRAL, MEDLINE, EMBASE, reference lists of articles and conference proceedings without language restriction to 10 April 2014. SELECTION CRITERIA Randomised and quasi-randomised controlled trials comparing different antibiotic agents, routes, frequencies or durations of therapy in children aged 0 to 18 years with proven UTI and acute pyelonephritis were selected. DATA COLLECTION AND ANALYSIS Four authors independently assessed study quality and extracted data. Statistical analyses were performed using the random-effects model and the results expressed as risk ratio (RR) for dichotomous outcomes or mean difference (MD) for continuous data with 95% confidence intervals (CI). MAIN RESULTS This updated review included 27 studies (4452 children). This update included evidence from three new studies, and following re-evaluation, a previously excluded study was included because it now met our inclusion criteria.Risk of bias was assessed as low for sequence generation (12 studies), allocation concealment (six studies), blinding of outcome assessors (17 studies), incomplete outcome reporting (19 studies) and selective outcome reporting (13 studies). No study was blinded for participants or investigators. The 27 included studies evaluated 12 different comparisons. No significant differences were found in duration of fever (2 studies, 808 children: MD 2.05 hours, 95% CI -0.84 to 4.94), persistent UTI at 72 hours after commencing therapy (2 studies, 542 children: RR 1.10, 95% CI 0.07 to 17.41) or persistent kidney damage at six to 12 months (4 studies, 943 children: RR 0.82, 95% CI 0.59 to 1.12) between oral antibiotic therapy (10 to 14 days) and intravenous (IV) therapy (3 days) followed by oral therapy (10 days). Similarly, no significant differences in persistent bacteriuria at the end of treatment (4 studies, 305 children: RR 0.78, 95% CI 0.24 to 2.55) or persistent kidney damage (4 studies, 726 children: RR 1.01, 95% CI 0.80 to 1.29) were found between IV therapy (three to four days) followed by oral therapy and IV therapy (seven to 14 days). No significant differences in efficacy were found between daily and thrice daily administration of aminoglycosides (1 study, 179 children, persistent clinical symptoms at three days: RR 1.98, 95% CI 0.37 to 10.53). Adverse events were mild and uncommon and rarely resulted in discontinuation of treatment. AUTHORS' CONCLUSIONS This updated review increases the body of evidence that oral antibiotics alone are as effective as a short course (three to four days) of IV antibiotics followed by oral therapy for a total treatment duration of 10 to 14 days for the treatment of acute pyelonephritis in children. When IV antibiotics are given, a short course (two to four days) of IV therapy followed by oral therapy is as effective as a longer course (seven to 10 days) of IV therapy. If IV therapy with aminoglycosides is chosen, single daily dosing is safe and effective. Insufficient data are available to extrapolate these findings to children aged less than one month of age or to children with dilating vesicoureteric reflux (grades III-V). Further studies are required to determine the optimal total duration of antibiotic therapy required for acute pyelonephritis.
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Affiliation(s)
- Yvonne Strohmeier
- University of SydneyWestmead Clinical SchoolCnr Darcy Rd and Hawksbury RdWestmeadNSWAustralia2145
| | - Elisabeth M Hodson
- The Children's Hospital at WestmeadCentre for Kidney ResearchLocked Bag 4001WestmeadNSWAustralia2145
- The University of SydneySydney School of Public HealthSydneyNSWAustralia2006
| | - Narelle S Willis
- The University of SydneySydney School of Public HealthSydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Renal Group, Centre for Kidney ResearchLocked Bag 4001WestmeadNSWAustralia2145
| | - Angela C Webster
- The University of SydneySydney School of Public HealthSydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Renal Group, Centre for Kidney ResearchLocked Bag 4001WestmeadNSWAustralia2145
- The University of Sydney at WestmeadCentre for Transplant and Renal Research, Westmead Millennium InstituteWestmeadNSWAustralia2145
| | - Jonathan C Craig
- The University of SydneySydney School of Public HealthSydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Renal Group, Centre for Kidney ResearchLocked Bag 4001WestmeadNSWAustralia2145
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Ferreiro C, Piepsz A, Nogarède C, Tondeur M, Hainaut M, Levy J. Late renal sequelae in intravenously treated complicated urinary tract infection. Eur J Pediatr 2013; 172:1243-8. [PMID: 23677250 DOI: 10.1007/s00431-013-2024-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Revised: 04/18/2013] [Accepted: 04/23/2013] [Indexed: 11/24/2022]
Abstract
BACKGROUND The treatment of complicated urinary tract infection in children is still a matter of debate. In our hospital, antimicrobial treatment is initiated intravenously, and the duration of this treatment is adapted according to the results of a Tc-99m dimercaptosuccinic acid (DMSA) scintigraphy. AIM This study was conducted to evaluate retrospectively the frequency and the importance of late renal sequelae when treating intravenously for 7 days those patients with an abnormal acute DMSA. METHODS A review was conducted of the medical charts of all patients consecutively admitted between 2005 and 2008 with positive urine culture and clinical and biological evidence of complicated urinary tract infection (UTI). RESULTS There were 144 patients (59 %) with abnormal early DMSA scintigraphy and 98 (41 %) with normal scintigraphy. The median duration of intravenous treatment was 7.0 days in the children with DMSA lesions and 5.0 days in those without lesions. Obvious renal sequelae were observed on late DMSA scintigraphy in 4 (6 %) out of the 65 patients with an abnormal early DMSA who came back for control scintigraphy. CONCLUSION Sequelae of acute DMSA lesions observed during complicated UTI treated 7 days intravenously were infrequent. Whether the mode and duration of antimicrobial treatment might explain the low rate of sequelae remains to be demonstrated.
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Affiliation(s)
- Christine Ferreiro
- Department of Pediatrics, Hospital Saint- Pierre, Université Libre de Bruxelles, Brussels, Belgium
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21
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Abstract
In infants and young children, urinary tract infections (UTI) often present with unspecific symptoms. Appropriate techniques of urine sampling play an important role for accurate microbiological diagnosis. In infants urine sampling by bladder puncture or transurethral catheter is recommended. In young infants with suspected pyelonephritis, calculated antibiotic treatment should be initiated parenterally with a combination of a third generation cephalosporin or an aminoglycoside with ampicillin. After the age of 3-6 months group 3 oral cephalosporins can be used in uncomplicated pyelonephritis. With the first febrile UTI early sonography is recommended to provide information about renal parenchymal involvement and to exclude malformations of the kidneys and urinary tract. Strategies for the recognition of vesicoureteral reflux and renal damage are under discussion. Recently published guidelines by the American Academy of Pediatrics for the diagnosis and management of UTI in febrile children and infants aged 2-24 months will most likely influence the still pending German guidelines.
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Affiliation(s)
- R Beetz
- Zentrum für Kinder- und Jugendmedizin, Universitätsmedizin Mainz, Johannes Gutenberg- Universität, Mainz.
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22
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Newman DH, Shreves AE, Runde DP. Pediatric urinary tract infection: does the evidence support aggressively pursuing the diagnosis? Ann Emerg Med 2013; 61:559-65. [PMID: 23312370 DOI: 10.1016/j.annemergmed.2012.10.034] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Revised: 10/22/2012] [Accepted: 10/25/2012] [Indexed: 11/17/2022]
Abstract
The epidemiology of pediatric fever has changed considerably during the past 2 decades with the development of vaccines against the most common bacterial pathogens causing bacteremia and meningitis. The decreasing incidence of these 2 conditions among vaccinated children has led to an emphasis on urinary tract infection as a remaining source of potentially hidden infections in febrile children. Emerging literature, however, has led to questions about both the degree and nature of the danger posed by urinary tract infection in nonverbal children, whereas the aggressive pursuit of the diagnosis consumes resources and leads to patient discomfort, medical risks, and potential overdiagnosis. We review both early and emerging literature to examine the utility and efficacy of early identification and treatment of urinary tract infection in children younger than 24 months. We conclude that in well children of this age, it may be reasonable to withhold or delay testing for urinary tract infection if signs of other sources are apparent or if the fever has been present for fewer than 4 to 5 days.
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23
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Bocquet N, Sergent Alaoui A, Jais JP, Gajdos V, Guigonis V, Lacour B, Chéron G. Étude randomisée comparant un traitement oral et un traitement séquentiel intraveineux puis oral pour le traitement des pyélonéphrites chez l’enfant. Étude de non infériorité. ANNALES FRANCAISES DE MEDECINE D URGENCE 2012. [DOI: 10.1007/s13341-012-0240-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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24
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Routh JC, Bogaert GA, Kaefer M, Manzoni G, Park JM, Retik AB, Rushton HG, Snodgrass WT, Wilcox DT. Vesicoureteral Reflux: Current Trends in Diagnosis, Screening, and Treatment. Eur Urol 2012; 61:773-82. [DOI: 10.1016/j.eururo.2012.01.002] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2011] [Accepted: 01/03/2012] [Indexed: 11/16/2022]
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Bocquet N, Sergent Alaoui A, Jais JP, Gajdos V, Guigonis V, Lacour B, Chéron G. Randomized trial of oral versus sequential IV/oral antibiotic for acute pyelonephritis in children. Pediatrics 2012; 129:e269-75. [PMID: 22291112 DOI: 10.1542/peds.2011-0814] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To confirm whether oral antibiotic treatment is as efficacious as sequential intravenous/oral antibiotic treatment in the prevention of renal scarring in children with acute pyelonephritis and scintigraphy-documented acute lesions. METHODS In a prospective multicenter trial, children aged 1 to 36 months with their first case of acute pyelonephritis, a serum procalcitonin concentration ≥0.5 ng/mL, no known uropathy, and a normal ultrasound exam were randomized into 2 treatment groups. They received either oral cefixime for 10 days or intravenous ceftriaxone for 4 days followed by oral cefixime for 6 days. Patients with acute renal lesions detected on early dimercaptosuccinic acid scintigraphy underwent a follow-up scintigraphy 6 to 8 months later. RESULTS The study included 171 infants and children. There were no significant differences between the 2 groups in any clinical characteristic. Initial scintigraphy results were abnormal for 119 children. Ninety-six children were measured for renal scarring at the follow-up scintigraphy (per protocol analysis population). The incidence of renal scarring was 30.8% in the oral treatment group and 27.3% for children who received the sequential treatment. CONCLUSIONS Although this trial does not statistically demonstrate the noninferiority of oral treatment compared with the sequential treatment, our study confirmed the results of previously published reports and therefore supports the use of an oral antibiotic treatment of primary episodes of acute pyelonephritis in infants and young children.
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Affiliation(s)
- Nathalie Bocquet
- Assistance Publique-Hôpitaux de Paris, Hôpital Necker Enfants Malades, France
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26
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de Lucas Collantes C, Cela Alvargonzalez J, Angulo Chacón AM, García Ascaso M, Piñeiro Pérez R, Cilleruelo Ortega MJ, Sánchez Romero I. [Urinary tract infections: antibiotic resistance and clinical follow up]. An Pediatr (Barc) 2011; 76:224-8. [PMID: 22104020 DOI: 10.1016/j.anpedi.2011.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2011] [Revised: 07/09/2011] [Accepted: 10/03/2011] [Indexed: 10/15/2022] Open
Abstract
The initial treatment of the urinary tract infections (UTI) is empirical and it is a priority to determine the antibiotic resistance of most common germs in a population. Furthermore, due to the suspicion of acute pyelonephritis the presence of renal scarring should be ruled out as this may lead to further complications. A retrospective longitudinal study was performed on all children under 14 years diagnosed with UTI from January 1 2009 to December 31 2009. The in vitro susceptibility to the most important urinary pathogens was analysed, along with the presence of scars, and a subsequent follow-up. The most frequently isolated bacteria were E. coli (80%), P. mirabilis (9.7%) and K. pneumoniae (4.2%). In the antibiogram, E coli showed a high sensitivity to fosfomycin (99.1%), cefotaxime (98.2%) cefuroxime (97.3%) and gentamicin (95.6%). The sensitivity obtained against amoxicillin-clavulanate was 83.2%, while that obtained against cotrimoxazole was 78.9%. Post-pyelonephritis scars were found in 19% of patients with febrile UTI, 17% out-patients and 20% of those admitted.
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Affiliation(s)
- C de Lucas Collantes
- Servicio de Pediatría, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España.
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Beetz R, Westenfelder M. Antimicrobial therapy of urinary tract infections in children. Int J Antimicrob Agents 2011; 38 Suppl:42-50. [PMID: 22036250 DOI: 10.1016/j.ijantimicag.2011.09.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
The main objectives in childhood urinary tract infections are rapid recovery from complaints, prevention of urosepsis and infection-related complications as well as the prevention of renal parenchymal damage. Calculated antibiotic therapy should take the local resistance rates of uropathogens into consideration. The current situation of bacterial resistances differs from region to region. In Escherichia coli, resistance rates against cephalosporins, aminoglycosides, nitrofurantoin und chinolones have been relatively low. In contrast, resistance rates against ampicillin have increased over the last 20 years. A similar trend has been observed for TMP/SMX. The choice of appropriate antibiotics, the duration of therapy and the form of application depend on age, severity of clinical symptoms and the presence of complicating factors. In early infancy, a combination of aminoglycoside/ampicillin or ceftazidime/ampicillin is commonly recommended as first-line treatment in pyelonephritis. Pyelonephritis in young infants should always be treated in a paediatric clinic. In later infancy and childhood, an oral third-generation cephalosporin can be used.
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Affiliation(s)
- Rolf Beetz
- Paediatric Nephrology, Center for Paediatric and Adolescent Medicine, University Medical Clinic, Langenbeckstr. 1, 55131 Mainz, Germany.
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28
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Cheng CH, Hang JF, Tsau YK, Lin TY. Nephromegaly is a significant risk factor for renal scarring in children with first febrile urinary tract infections. J Urol 2011; 186:2353-7. [PMID: 22019042 DOI: 10.1016/j.juro.2011.07.112] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2011] [Indexed: 11/29/2022]
Abstract
PURPOSE We determined whether nephromegaly on ultrasound can be used to identify patients with urinary tract infection at increased risk for renal scarring, and we investigated the effect of vesicoureteral reflux on renal scarring. MATERIALS AND METHODS We enrolled hospitalized patients with a first febrile urinary tract infection. All patients underwent renal ultrasound and most patients underwent voiding cystourethrography. Renal scarring was assessed using (99m)technetium dimercapto-succinic acid renal scintigraphy at least 6 months after treatment. Children with recurrent urinary tract infections before scintigraphy were excluded from the study. RESULTS A total of 545 children (80 with and 465 without nephromegaly) were enrolled. Infection was more severe in patients with than without nephromegaly. The incidence of renal scarring was significantly higher in patients with nephromegaly (90% vs 32%, p <0.001), in kidneys with nephromegaly (80.5% vs 18.7%, p <0.001) and in kidneys with vesicoureteral reflux (41.5% vs 22.2%, p <0.001). Kidneys with nephromegaly had a greater incidence of reflux. The finding of nephromegaly is associated with a greatly increased likelihood of renal scarring in patients with vesicoureteral reflux. CONCLUSIONS Our results indicate that ultrasound diagnosis of nephromegaly at onset is associated with a high incidence of renal scarring, and identification of nephromegaly at onset and vesicoureteral reflux are significant risk factors for renal scarring in children with a first febrile urinary tract infection. Nephromegaly is associated with an increased frequency of vesicoureteral reflux and increased likelihood of renal scarring in patients with reflux.
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Affiliation(s)
- Chi-Hui Cheng
- Department of Pediatrics, Chang Gung Children's Hospital, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
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Ayazi P, Moshiri SA, Mahyar A, Moradi M. The effect of vitamin A on renal damage following acute pyelonephritis in children. Eur J Pediatr 2011; 170:347-50. [PMID: 20853007 DOI: 10.1007/s00431-010-1297-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2010] [Accepted: 09/07/2010] [Indexed: 11/26/2022]
Abstract
Animal studies suggest that administration of vitamin A to rats with experimental urinary tract infection decreases the frequency of renal scars (Kavukçu et al., BJU Int 83(9):1055-1059, 1999). The aim of this study was to determine the effect of vitamin A on the rate of permanent renal damage in children with acute pyelonephritis. Fifty children, median age of 24 months (range 2-144), with first-time pyelonephritis verified by an uptake defect on acute dimercaptosuccinic acid (DMSA) scan were included in the study and randomly allocated to the case or control groups. All were given intravenous ceftriaxone for 10 days followed by oral cephalexin for 3 months. Cases in addition were given a single intramuscular dose of vitamin A, 25,000 U for infants below 1 year of age and 50,000 U for older children. At the repeat DMSA scan after 3 months, five of 25 cases (20%) and 17 of 25 controls (68%) had abnormal findings (p = 0.001). In conclusion, administration of vitamin A was associated with a significantly lower rate of permanent renal damage.
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Affiliation(s)
- Parviz Ayazi
- Department of Pediatric Infectious Diseases, Clinical Research Center, Qazvin Children Hospital, Qazvin University of Medical Sciences, Qazvin, Iran.
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Acute lobar nephronia is associated with a high incidence of renal scarring in childhood urinary tract infections. Pediatr Infect Dis J 2010; 29:624-8. [PMID: 20234330 DOI: 10.1097/inf.0b013e3181d8631a] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute lobar nephronia (ALN) is a severe nonliquefactive inflammatory renal bacterial infection, and requires a longer duration of treatment. The aim of this prospective study was to investigate renal scarring after ALN and to examine the risk factors for renal scarring in children with ALN compared with those with acute pyelonephritis (APN). METHODS Patients with computed tomography-diagnosed ALN were enrolled and randomly allocated, with serial entry, to either a 2- or 3-week antibiotic treatment regimen. Age- and gender-matched APN patients served as comparators. Patients underwent dimercaptosuccinic acid scintigraphy at least 6 months later to assess renal scarring. RESULTS A total of 218 children (109 ALN, 109 APN) were enrolled. The incidence of renal scarring was similar between 2- and 3-week treatment groups and was higher in ALN patients than in APN patients (89.0% vs. 34.9%, P < 0.001). Renal scarring was prone to occur in children with higher inflammatory indices and longer duration of fever before and after treatment. Multiple regression analysis on independent variables showed that only ALN was significantly associated with a higher incidence of renal scarring. CONCLUSIONS Our results showed a new finding that ALN is associated with a very high incidence of renal scarring, in comparison to APN, irrespective of the duration of antibiotic treatment.
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Clark CJ, Kennedy WA, Shortliffe LD. Urinary Tract Infection in Children: When to Worry. Urol Clin North Am 2010; 37:229-41. [DOI: 10.1016/j.ucl.2010.03.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Kouranos VD, Karageorgopoulos DE, Peppas G, Falagas ME. Comparison of adverse events between oral and intravenous formulations of antimicrobial agents: a systematic review of the evidence from randomized trials. Pharmacoepidemiol Drug Saf 2009; 18:873-9. [PMID: 19653237 DOI: 10.1002/pds.1809] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Some clinicians may favor a strategy of early switch to oral antimicrobial therapy for patients responding to initial intravenous therapy. An important relevant consideration refers to the comparative safety and tolerability between oral and intravenous antimicrobial therapy. LITERATURE SEARCH/STUDY SELECTION: We sought to evaluate the above-mentioned issue by performing a systematic review of randomized studies comparing the occurrence of adverse events between oral and intravenous antimicrobial therapy with the same agents. FINDINGS Ten relevant studies (five randomized controlled trials, three randomized cross-over studies, and two randomized, placebo-controlled, parallel-design studies) were included. Seven of the studies evaluated antibacterials (fluoroquinolones in four, and telithromycin, amoxicillin-clavulanic acid, and linezolid in one study each, respectively), whereas two studies evaluated ganciclovir, and one evaluated isavuconazole. No difference was observed in the rate of total adverse events between oral and intravenous administration of the same antimicrobial agents in any of the included studies that reported specific relevant data. Injection site reactions were noted more frequently with intravenous treatment in one study. No serious drug-related adverse events were reported, while study withdrawals due to adverse events did not considerably differ between the compared groups in any of the included studies. CONCLUSION There are only limited comparative data regarding the adverse events associated with the administration of the same antimicrobial agents by the oral and intravenous route. Our review indicates that the adverse event profile of oral and intravenous antimicrobial therapy does not differ considerably; however, this issue requires validation by further studies.
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Zaffanello M, Cataldi L, Brugnara M, Franchini M, Bruno C, Fanos V. Hidden high-grade vesicoureteral reflux is the main risk factor for chronic renal damage in children under the age of two years with first urinary tract infection. ACTA ACUST UNITED AC 2009; 43:494-500. [DOI: 10.3109/00365590903286663] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Marco Zaffanello
- Department of Mother–Child and Biology–Genetics, University of Verona, Verona, Italy
| | - Luigi Cataldi
- Division of Neonatology, Catholic University of Sacred Heart, Rome, Italy
| | - Milena Brugnara
- Department of Mother–Child and Biology–Genetics, University of Verona, Verona, Italy
| | - Massimo Franchini
- Immunohematology and Transfusion Center, Department of Pathology and Laboratory Medicine, University Hospital of Parma, Parma, Italy
| | - Costanza Bruno
- Department of Morphological–Biomedical Science, University of Verona, Verona, Italy
| | - Vassilios Fanos
- Neonatal Intensive Care Unit, University of Cagliari, Cagliari, Italy
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Bensman A, Ulinski T. Pharmacotherapy of lower urinary tract infections and pyelonephritis in children. Expert Opin Pharmacother 2009; 10:2075-80. [DOI: 10.1517/14656560903095273] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Vouloumanou EK, Rafailidis PI, Kazantzi MS, Athanasiou S, Falagas ME. Early switch to oral versus intravenous antimicrobial treatment for hospitalized patients with acute pyelonephritis: a systematic review of randomized controlled trials. Curr Med Res Opin 2008; 24:3423-34. [PMID: 19032124 DOI: 10.1185/03007990802550679] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Acute pyelonephritis is a common infection with significant morbidity and mortality, particularly in pediatric populations. Early-switch strategies (from intravenous to oral treatment) may be an acceptable or even preferred option in the treatment of patients with acute pyelonephritis in terms of effectiveness and safety and can also reduce the economical burden associated with pyelonephritis. OBJECTIVE We sought to evaluate the effectiveness and safety of early-switch strategies in hospitalized patients with acute uncomplicated pyelonephritis. METHODS We searched in PubMed, Cochrane Central Register of Controlled Trials, and Scopus to identify randomized controlled trials (RCTs) that compared intravenous antibiotic regimens to regimens including an early switch to oral (after initial intravenous) treatment. RESULTS Eight RCTs (6 in children) were eligible for inclusion. In 5 RCTs the intravenous antibiotic treatment arms were not switched to oral treatment until the end of the study while in the remaining 3 RCTs the intravenous arms were switched late to oral treatment (after 5-10 days). Data regarding the incidence of renal scars, microbiological eradication, clinical cure, reinfection, persistence of acute pyelonephritis, and adverse events were provided in 4 (all pediatric trials), 6 (4 pediatric), 4 (2 pediatric), 5 (3 pediatric), 3 (1 pediatric), and 5 RCTs (3 pediatric), respectively. There were no differences regarding the above outcomes between the two compared treatment regimens in either pediatric or adult populations. CONCLUSION Early switch to oral antibiotic strategies seem to be as effective and safe as intravenous regimens for the treatment of hospitalized patients with acute pyelonephritis. These findings suggest that there is probably a potential to decrease the duration of intravenous treatment by 4-11 days in hospitalized patients with acute pyelonephritis without compromising their outcomes.
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Michael M, Hodson EM, Craig JC, Martin S, Moyer VA. Short versus standard duration oral antibiotic therapy for acute urinary tract infection in children. Cochrane Database Syst Rev 2003:CD003966. [PMID: 12535494 DOI: 10.1002/14651858.cd003966] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The optimal duration of oral antibiotic therapy for urinary tract infection (UTI) in children has not been determined. A number of studies have compared single dose therapy to standard therapy for UTI, with mixed results. A course of antibiotics longer than a single dose but shorter than the usual 7-10 days might decrease the relapse rate and still provide some of the benefits of a shortened course of antibiotics. OBJECTIVES The objective of this review was to assess the benefits and harms of short-course (2-4 days) compared to standard duration (7-14 days) oral antibiotic treatment for acute UTI in children. SEARCH STRATEGY We searched the Cochrane Controlled Trials Register (Cochrane Library Issue 3, 2002) MEDLINE (1966 - September 2002) and EMBASE (1988 -September 2002) without language restriction. SELECTION CRITERIA Randomised and quasi-randomised controlled trials comparing short-term (2-4 days) with standard (7-14 days) oral antibiotic therapy were selected if they studied children aged three months to 18 years with culture proven UTI. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed trial quality and extracted data. Statistical analyses were performed using the random effects model and the results expressed as relative risk (RR) with 95% confidence intervals (95% CI). MAIN RESULTS Ten trials were identified in which 652 children with lower tract UTI were evaluated. There was no significant difference in the frequency of positive urine cultures between the short (2-4 days) and standard duration oral antibiotic therapy (7-14 days) for UTI in children at 0-10 days after treatment (eight studies: RR 1.06; 95% CI 0.64 to 1.76) and at one to 15 months after treatment (10 studies: RR 0.95; 95% CI 0.70 to 1.29). There was no significant difference between short and standard duration therapy in the development of resistant organisms in UTI at the end of treatment (one study: RR 0.57, 95% CI 0.32 to 1.01) or in recurrent UTI (three studies: RR 0.39, 95% CI 0.12 to 1.29). REVIEWER'S CONCLUSIONS A 2-4 day course of oral antibiotics appears to be as effective as 7-14 days in eradicating lower tract UTI in children.
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Affiliation(s)
- M Michael
- The Centre for Kidney Research, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW, Australia, 2145.
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