1
|
Rius-Gordillo N, Ferré N, González JD, Ibars Z, Parada-Ricart E, Escribano J. Role of dexamethasone in controlling the proinflammatory cytokine cascade in the first episode of paediatric acute pyelonephritis. Acta Paediatr 2024; 113:564-572. [PMID: 37965887 DOI: 10.1111/apa.17034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/26/2023] [Accepted: 10/31/2023] [Indexed: 11/16/2023]
Abstract
AIM Febrile urinary tract infection is a common bacterial infection in childhood. The kidney damage after acute pyelonephritis (APN) could be related to the stimulation of the proinflammatory response. We aimed to investigate the role of inflammatory cytokines and the effect of dexamethasone after a first episode of APN. METHODS Subanalysis of the DEXCAR RCT in which children with confirmed APN (1 month-14 years) were randomly assigned to receive a 3 days course of either intravenous dexamethasone or placebo. Urinary cytokine levels at diagnosis and after 72 h of treatment were measured. RESULTS Ninety-two patients were recruited. Younger patients, males and those with abnormalities in the ultrasound study or vesicoureteral reflux showed higher values of urinary cytokines. Patients with severe APN had higher Tumour Necrosis Factor (TNF)α levels (81.0 ± 75.8 vs. 33.6 ± 48.5 pg/mg creatinine, p = 0.015). Both intervention groups showed similar basal clinical characteristics, including urinary cytokine levels. Treatment reduced urinary cytokine levels irrespective of dexamethasone administration. Neither the intervention group nor the urinary cytokine levels modulated the development of kidney scars. CONCLUSION Basal urinary cytokines were associated with age, abnormal ultrasound and vesicoureteral reflux. Patients with severe APN had higher TNFa urinary levels. Administration of dexamethasone in children with APN does not improve the control of the proinflammatory cytokine cascade.
Collapse
Affiliation(s)
- Neus Rius-Gordillo
- Paediatrics Unit, Hospital Universitari Sant Joan de Reus, Reus, Spain
- Paediatric Nutrition and Human Development Research Unit, Universitat Rovira i Virgili, Reus, Spain
- Institut d'Investigació Sanitaria Pere Virgili, Tarragona, Spain
| | - Natàlia Ferré
- Paediatric Nutrition and Human Development Research Unit, Universitat Rovira i Virgili, Reus, Spain
- Institut d'Investigació Sanitaria Pere Virgili, Tarragona, Spain
| | - Juan David González
- Paediatrics Unit, Hospital General Universitario Santa Lucia, Cartagena, Spain
| | - Zaira Ibars
- Paediatrics Unit, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - Ester Parada-Ricart
- Paediatric Nutrition and Human Development Research Unit, Universitat Rovira i Virgili, Reus, Spain
- Institut d'Investigació Sanitaria Pere Virgili, Tarragona, Spain
- Paediatrics Unit, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain
| | - Joaquín Escribano
- Paediatrics Unit, Hospital Universitari Sant Joan de Reus, Reus, Spain
- Paediatric Nutrition and Human Development Research Unit, Universitat Rovira i Virgili, Reus, Spain
- Institut d'Investigació Sanitaria Pere Virgili, Tarragona, Spain
| |
Collapse
|
2
|
Gkiourtzis N, Glava A, Moutafi M, Vasileiadou T, Delaporta T, Michou P, Printza N, Makedou K, Tramma D. The efficacy and safety of corticosteroids in pediatric kidney scar prevention after urinary tract infection: a systematic review and meta-analysis of randomized clinical trials. Pediatr Nephrol 2023; 38:3937-3945. [PMID: 36943468 PMCID: PMC10584697 DOI: 10.1007/s00467-023-05922-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 02/07/2023] [Accepted: 02/13/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Acute pyelonephritis (APN) in pediatric patients may lead to kidney scarring and is one of the main causes of permanent kidney damage. The incidence of kidney scarring after one febrile urinary tract infection (UTI) is reported to range from 2.8 to 15%, with the percentage rising to 28.6% after ≥ 3 febrile UTIs. Corticosteroids may have a role in the reduction of kidney scar formation and urine cytokine levels. The possible benefit of adjuvant corticosteroid administration in the reduction of kidney scar formation in children with APN has been recently examined in randomized controlled trials (RCTs). OBJECTIVES The aim of this meta-analysis was to provide a summary of the current literature about the efficacy and safety of adjuvant corticosteroid administration in the reduction of kidney scar formation in children with APN. DATA SOURCES An extensive literature search through major databases (PubMed/MEDLINE and Scopus) was carried out for RCTs from inception until October 12, 2022, investigating the efficacy and safety of adjuvant corticosteroids in preventing kidney scarring in children with APN. A risk ratio with 95% CI was used for dichotomous outcomes. RESULTS In total, 5 RCTs with 918 pediatric patients with APN were included in the study. Adjuvant corticosteroid treatment revealed a statistically significant reduction in kidney scarring (95% CI 0.42-0.95, p = 0.03), without increasing the risk of adverse events like bacteremia, prolonged hospitalization, or recurrence of UTI. LIMITATIONS There were limitations regarding sample size (n = 498 children), different classes of corticosteroids (methylprednisolone or dexamethasone), different routes of corticosteroid administration (intravenous or oral), and different day courses (3-day or 4-day course). CONCLUSIONS Adjuvant corticosteroid administration seems to have a beneficial effect on kidney scar reduction in children with APN. Future studies should focus on the evaluation of the efficacy and safety of corticosteroids in kidney scarring reduction after APN to strengthen the results of our study. A higher resolution version of the Graphical abstract is available as Supplementary information.
Collapse
Affiliation(s)
- Nikolaos Gkiourtzis
- 4th Department of Pediatrics, Papageorgiou General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Agni Glava
- 4th Department of Pediatrics, Papageorgiou General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria Moutafi
- 4th Department of Pediatrics, Papageorgiou General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theopisti Vasileiadou
- 4th Department of Pediatrics, Papageorgiou General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theodora Delaporta
- 4th Department of Pediatrics, Papageorgiou General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Panagiota Michou
- Pediatric Department, G. Gennimatas General Hospital, Thessaloniki, Greece
| | - Nikoleta Printza
- 1st Department of Pediatrics, Ippokrateio General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Kali Makedou
- Laboratory of Biochemistry, School of Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Despoina Tramma
- 4th Department of Pediatrics, Papageorgiou General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| |
Collapse
|
3
|
Jääskeläinen J, Renko M, Kuitunen I. Corticosteroids to prevent renal scarring in children with pyelonephritis: a systematic review and meta-analysis. J Nephrol 2023:10.1007/s40620-022-01552-1. [PMID: 36692666 PMCID: PMC10393849 DOI: 10.1007/s40620-022-01552-1] [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: 09/12/2022] [Accepted: 12/03/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Acute pyelonephritis is a common infection in children that may cause renal scarring. The aim of this systematic review and meta-analysis was to analyse the use of corticosteroid treatment to prevent renal scarring. METHODS We searched the PubMED, SCOPUS, Cochrane CENTRAL and Web of Science databases in June 2022 for (corticosteroid* or dexamethasone or prednisolone* or prednisone* or hydrocortisone*) AND pyelonephritis. Randomised controlled trials focusing on children were included. The intervention was corticosteroid treatment with antibiotics compared to antibiotics with or without a placebo. The main outcome was the presence of renal scars on dimercaptosuccinic acid scanning at follow-up. The evidence quality was assessed using the GRADE methodology and risk of bias 2.0 tool. We calculated the risk ratio (RR), absolute risk difference (RD) with 95% confidence intervals (CI) and the number needed to treat (NNT). We applied a fixed effects model due to low heterogeneity. RESULTS We screened 872 abstracts and included five full texts. Renal scarring at follow-up was found in 31/220 (14.1%) patients in the corticosteroid groups and 76/278 (27.3%) in the control groups (RR 0.65, CI 0.44-0.96, RD - 13.2%, NNT 8). The evidence quality was moderate. Two studies reported adverse events with no differences between the groups. The risk of bias analysis showed some concerns in four studies. CONCLUSION We found moderate quality evidence that adjuvant corticosteroid treatment could prevent renal scarring. Adverse events were insufficiently reported, and more research on their effectiveness and harm is therefore needed before using corticosteroids in clinical settings.
Collapse
Affiliation(s)
- Johanna Jääskeläinen
- Institute of Clinical Medicine and Department of Pediatrics, University of Eastern Finland, Yliopistonranta 2, 70211, Kuopio, Finland.
| | - Marjo Renko
- Institute of Clinical Medicine and Department of Pediatrics, University of Eastern Finland, Yliopistonranta 2, 70211, Kuopio, Finland
- Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland
| | - Ilari Kuitunen
- Institute of Clinical Medicine and Department of Pediatrics, University of Eastern Finland, Yliopistonranta 2, 70211, Kuopio, Finland
- Department of Pediatrics, Mikkeli Central Hospital, Mikkeli, Finland
| |
Collapse
|
4
|
Rius-Gordillo N, Ferré N, González JD, Ibars Z, Parada-Ricart E, Fraga MG, Chocron S, Samper M, Vicente C, Fuertes J, Escribano J. Dexamethasone to prevent kidney scarring in acute pyelonephritis: a randomized clinical trial. Pediatr Nephrol 2022; 37:2109-2118. [PMID: 35041042 PMCID: PMC9307518 DOI: 10.1007/s00467-021-05398-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 12/04/2021] [Accepted: 12/06/2021] [Indexed: 10/25/2022]
Abstract
BACKGROUND Urinary tract infection (UTI) is one of the most common bacterial infections in childhood and is associated with long-term complications. We aimed to assess the effect of adjuvant dexamethasone treatment on reducing kidney scarring after acute pyelonephritis (APN) in children. METHODS Multicenter, prospective, double-blind, placebo-controlled, randomized clinical trial (RCT) where children from 1 month to 14 years of age with proven APN were randomly assigned to receive a 3-day course of either an intravenous corticosteroid (dexamethasone 0.30 mg per kg/day) twice daily or placebo. The late technetium 99 m-dimercaptosuric acid scintigraphy (> 6 months after acute episode) was performed to assess kidney scar persistence. Kidney scarring risk factors (vesicoureteral reflux, kidney congenital anomalies, or urinary tract dilatation) were also assessed. RESULTS Ninety-one participants completed the follow-up and were finally included (dexamethasone n = 49 and placebo n = 42). Both groups had similar baseline characteristics. Twenty participants showed persistent kidney scarring after > 6 months of follow-up without differences in incidence between groups (22% and 21% in the dexamethasone and placebo groups, p = 0.907). Renal damage severity in the early DMSA (β = 0.648, p = 0.023) and procalcitonin values (β = 0.065 p = 0.027) significantly modulated scar development. Vesicoureteral reflux grade showed a trend towards significance (β = 0.545, p = 0.054), but dexamethasone treatment showed no effect. CONCLUSION Dexamethasone showed no effect on reducing the risk of scar formation in children with APN. Hence, there is no evidence for an adjuvant corticosteroid treatment recommendation in children with APN. However, the study was limited by not achieving the predicted sample size and the expected scar formation. TRIAL REGISTRATION Clinicaltrials.gov, NCT02034851. Registered in January 14, 2014. "A higher resolution version of the Graphical abstract is available as Supplementary information."
Collapse
Affiliation(s)
- Neus Rius-Gordillo
- Pediatrics Unit, Hospital Universitari Sant Joan de Reus, Reus, Spain
- Pediatric Nutrition and Human Development Research Unit, Universitat Rovira i Virgili, Reus, Spain
- Institut d'Investigació Sanitaria Pere Virgili, Tarragona, Spain
| | - Natàlia Ferré
- Pediatrics Unit, Hospital Universitari Sant Joan de Reus, Reus, Spain
- Institut d'Investigació Sanitaria Pere Virgili, Tarragona, Spain
| | - Juan David González
- Pediatrics Unit, Hospital General Universitario Santa Lucia, Cartagena, Spain
| | - Zaira Ibars
- Pediatrics Unit, Hospital Universitari Arnau de Vilanova, 25198, Lleida, Spain
| | - Ester Parada-Ricart
- Pediatric Nutrition and Human Development Research Unit, Universitat Rovira i Virgili, Reus, Spain
- Institut d'Investigació Sanitaria Pere Virgili, Tarragona, Spain
- Pediatrics Unit, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain
| | | | - Sara Chocron
- Pediatrics Unit, Hospital Universitari General Catalunya, Sant Cugat, Spain
| | - Manuel Samper
- Pediatrics Unit, Pius Hospital de Valls, Valls, Spain
| | - Carmen Vicente
- Nephrology Department, Pediatrics Service, Hospital Clínico Universitario Virgen de La Arrixaca, Murcia, Spain
| | - Jordi Fuertes
- Nuclear Medicine Service, Hospital Universitari Sant Joan de Reus, Reus, Spain
| | - Joaquín Escribano
- Pediatrics Unit, Hospital Universitari Sant Joan de Reus, Reus, Spain.
- Pediatric Nutrition and Human Development Research Unit, Universitat Rovira i Virgili, Reus, Spain.
- Institut d'Investigació Sanitaria Pere Virgili, Tarragona, Spain.
- Institut d'Investigació Sanitaria Pere Virgili, Sant Lloreç 21, 43201, Reus, Spain.
| |
Collapse
|
5
|
Olson P, Dudley AG, Rowe CK. Contemporary Management of Urinary Tract Infections in Children. CURRENT TREATMENT OPTIONS IN PEDIATRICS 2022; 8:192-210. [PMID: 37521173 PMCID: PMC9108690 DOI: 10.1007/s40746-022-00242-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 04/17/2022] [Indexed: 10/29/2022]
Abstract
Purpose of Review Urinary tract infection (UTI) in children is a major source of office visits and healthcare expenditure. Research into the diagnosis, treatment, and prophylaxis of UTI has evolved over the past 10 years. The development of new imaging techniques and UTI screening tools has improved our diagnostic accuracy tremendously. Identifying who to treat is imperative as the increase in multi-drug-resistant organisms has emphasized the need for antibiotic stewardship. This review covers the contemporary management of children with UTI and the data-driven paradigm shifts that have been implemented into clinical practice. Recent Findings With recent data illustrating the self-limiting nature and low prevalence of clinically significant vesicoureteral reflux (VUR), investigational imaging in children has become increasingly less frequent. Contrast-enhanced voiding urosonogram (CEVUS) has emerged as a useful diagnostic tool, as it can provide accurate detection of VUR without the need of radiation. The urinary and intestinal microbiomes are being investigated as potential therapeutic drug targets, as children with recurrent UTIs have significant alterations in bacterial proliferation. Use of adjunctive corticosteroids in children with pyelonephritis may decrease the risk of renal scarring and progressive renal insufficiency. The development of a vaccine against an antigen present on Escherichia coli may change the way we treat children with recurrent UTIs. Summary The American Academy of Pediatrics defines a UTI as the presence of at least 50,000 CFU/mL of a single uropathogen obtained by bladder catheterization with a dipstick urinalysis positive for leukocyte esterase (LE) or WBC present on urine microscopy. UTIs are more common in females, with uncircumcised males having the highest risk in the first year of life. E. coli is the most frequently cultured organism in UTI diagnoses and multi-drug-resistant strains are becoming more common. Diagnosis should be confirmed with an uncontaminated urine specimen, obtained from mid-stream collection, bladder catheterization, or suprapubic aspiration. Patients meeting criteria for imaging should undergo a renal and bladder ultrasound, with further investigational imaging based on results of ultrasound or clinical history. Continuous antibiotic prophylaxis is controversial; however, evidence shows patients with high-grade VUR and bladder and bowel dysfunction retain the most benefit. Open surgical repair of reflux is the gold standard for patients who fail medical management with endoscopic approaches available for select populations.
Collapse
Affiliation(s)
- Philip Olson
- Department of Urology, University of Connecticut School of Medicine, 200 Academic Way, Farmington, CT 06032 USA
| | - Anne G. Dudley
- Division of Pediatric Urology, Connecticut Children’s, 282 Washington Street, Hartford, CT 06106 USA
| | - Courtney K. Rowe
- Division of Pediatric Urology, Connecticut Children’s, 282 Washington Street, Hartford, CT 06106 USA
| |
Collapse
|
6
|
Zhu HM, Yuan CH, Luo MQ, Deng XL, Huang S, Wu GF, Hu JS, Yao C, Liu ZS. Safety and Effectiveness of Oral Methylprednisolone Therapy in Comparison With Intramuscular Adrenocorticotropic Hormone and Oral Prednisolone in Children With Infantile Spasms. Front Neurol 2022; 12:756746. [PMID: 35002921 PMCID: PMC8727336 DOI: 10.3389/fneur.2021.756746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 11/26/2021] [Indexed: 11/30/2022] Open
Abstract
Background and Purpose: To assess the safety and effectiveness of oral methylprednisolone (oMP) in comparison with intramuscular adrenocorticotropic hormone (imACTH) and oral prednisolone (oP) therapies in children with infantile spasms (IS). Methods: In this prospective, open-label, non-blinded, uncontrolled observational study, children (aged 2–24 months) with newly diagnosed IS presenting with hypsarrhythmia or its variants on electroencephalogram (EEG) were included. It was followed by imACTH, oP, or oMP (32–48 mg/day for 2 weeks followed by tapering) treatments. Electroclinical remission/spasm control, relapse, and adverse effects were evaluated in the short-term (days 14 and 42) and intermediary-term (3, 6, and 12 months) intervals. Results: A total of 320 pediatric patients were enrolled: 108, 107, and 105 in the imACTH, oMP, and oP groups, respectively. The proportion of children achieving electroclinical remission on days 14 and 42 was similar among the three groups (day 14: 53.70 vs. 60.75 vs. 51.43%, p = 0.362; day 42: 57.55 vs. 63.46 vs. 55.34%, p = 0.470). The time to response was significantly faster in the oMP group (6.5 [3.00, 10.00] days vs. 8.00 [5.00, 11.00] days for imACTH and 8.00 [5.00, 13.00] days for oP, p = 0.025). Spasm control at 3, 6, and 12 months was also similar in the three groups (P = 0.775, 0.667, and 0.779). The relapse rate in the imACTH group (24.10%) was lower than oMP (30.77%) and oP groups (33.33%), and the time taken for relapse in the imACTH group (79.00 [56.50, 152.00] days) was longer than oMP (62.50 [38.00, 121.75] days) and oP groups (71.50 [40.00, 99.75] days), but the differences were not statistically significant (p = 0.539 and 0.530, respectively). The occurrence of adverse effects was similar among the three groups. Conclusions: The short and intermediary-term efficacy and recurrence rates of oMP are not inferior to those of imACTH and oP for the treatment of IS. Significantly, the time to achieve electroclinical remission with oMP was quicker than that with imACTH and oP. Considering its convenience, affordability, and the absence of irreversible side effects, oMP can serve as a form of first-line treatment for newly diagnosed IS.
Collapse
Affiliation(s)
- Hong-Min Zhu
- Department of Neurology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chun-Hui Yuan
- Department of Laboratory Medicine, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Meng-Qing Luo
- Department of Neurology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Department of Rehabilitation Medicine, Wuhan First Hospital, Wuhan, China
| | - Xiao-Long Deng
- Department of Neurology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Sheng Huang
- Department of Neurology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ge-Fei Wu
- Department of Neurology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jia-Sheng Hu
- Department of Neurology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Cong Yao
- Health Care Department, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhi-Sheng Liu
- Department of Neurology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
7
|
Sedighi I, Taheri-Moghadam G, Emad-Momtaz H, Vaseghi G, Eshraghi A, Asnaashari F, Mehrpooya M. Protective Effects of Omega-3 Fatty Acids Supplementation Against Renal Parenchymal Scarring in Children with Acute Pyelonephritis: Results of a Pilot Clinical Trial. Curr Pediatr Rev 2022; 18:72-81. [PMID: 34503428 DOI: 10.2174/1573396317666210909153643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 06/05/2021] [Accepted: 06/30/2021] [Indexed: 11/22/2022]
Abstract
AIM This trial aimed to determine if supplementation with omega-3 fatty acids as an adjunct therapy to antibiotic treatment can have protective effects against renal scar formation after acute pyelonephritis (APN) in pediatric patients. BACKGROUND Current evidence points out that besides antibiotic treatment, early administration of antioxidant and anti-inflammatory compounds may be effective in reducing the occurrence of renal damage following APN in children. OBJECTIVE The main endpoint of the trial was the comparison of the development of renal scarring formation after APN in an omega-3 fatty acids-treated group and in a control-treated group. METHODS This prospective randomized, controlled trial study was conducted from March 2016 to May 2018 on 60 children with a diagnosis APN in a tertiary hospital in Iran. After the diagnosis of APN based on the clinical signs and symptoms, urine analysis, urine culture, and dimercaptosuccinic acid renal scan (DMSA scan), the patients were randomly allocated into either the control group (n=30 patients: received standard antibiotic treatment only) or the intervention group (n=30 patients: received standard antibiotic-treatment in combination with oral omega-3 fatty acids based on the children's weight for three consecutive days). A second DMSA scan was performed for the patients at a minimum of six months after treatment. The development of renal scars was evaluated by comparing the baseline DMSA scan lesions with the follow-up DMSA scan lesions. RESULTS Fifty patients, including 26 and 24 individuals in the control and intervention groups, respectively, completed the entire course of the study. Renal parenchymal involvement based on the baseline DMSA scan was similar in the two groups (p-value =0.85, 0.90, and 0.53 regarding the right, left, and both kidney units together, respectively). Although comparison of the follow-up DMSA scan lesions to the baseline DMSA scan lesions considering the right and left kidneys as separate units between two groups did not reach the significant level, when considering both left and right kidney units together, results showed a statistically significant difference between groups in favor of the intervention group (p-value =0.04). CONCLUSION Although preliminary, the results of this study showed that administration of omega-3 fatty acids, a natural supplement with well-known anti-inflammatory and antioxidant properties, as an adjunct therapy to standard antibiotic treatment might significantly reduce the incidence of the occurrence renal scarring following APN in children. Confirmation of these results requires further studies.
Collapse
Affiliation(s)
- Iraj Sedighi
- Pediatrics Department, Faculty of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Ghazal Taheri-Moghadam
- Department of Clinical Pharmacy, School of Pharmacy, Medicinal Plants and Natural Products Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Hossein Emad-Momtaz
- Division of Pediatric Nephrology, Besat Hospital, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Golnaz Vaseghi
- Applied Physiology Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Azadeh Eshraghi
- Department of Clinical Pharmacy, School of Pharmacy, Iran University of Medical Sciences, Tehran, Iran
| | - Farzaneh Asnaashari
- Department of Community and Preventive Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Maryam Mehrpooya
- Department of Clinical Pharmacy, School of Pharmacy, Medicinal Plants and Natural Products Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
| |
Collapse
|
8
|
Meena J, Kumar J. Adjuvant corticosteroids for prevention of kidney scarring in children with acute pyelonephritis: a systematic review and meta-analysis. Arch Dis Child 2021; 106:1081-1086. [PMID: 33632785 DOI: 10.1136/archdischild-2020-320591] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 01/21/2021] [Accepted: 02/10/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Acute pyelonephritis in children may result in permanent kidney scarring that is primarily caused by inflammation during acute infection. Antibiotic therapy alone is not enough to significantly reduce kidney scarring, and adjuvant corticosteroid therapy has shown a significant reduction in inflammatory cytokines in urine prompting its evaluation in randomised controlled trials. A few clinical trials showed a trend towards a reduction in renal scarring but did not have an adequate sample size to show a significant effect. Therefore, we planned to synthesise the available evidence on the role of corticosteroids as adjuvant therapy in reducing kidney scarring. OBJECTIVE To assess the efficacy and safety of adjuvant corticosteroid therapy for the prevention of kidney scarring in children with acute pyelonephritis. DESIGN Systematic review and meta-analysis. SETTING Community-acquired febrile urinary tract infections. PATIENTS Children (less than 18 years) with acute pyelonephritis. INTERVENTION Adjuvant corticosteroid therapy (along with antibiotic treatment). MAIN OUTCOME MEASURES Primary: efficacy in preventing kidney scarring; secondary: serious adverse events associated with corticosteroid therapy. RESULTS Three randomised trials (529 children) were included. Corticosteroids are effective in lowering the risk of kidney scarring as compared with placebo (risk ratio (RR): 0.57; 95% CI 0.36 to 0.90). No significant increase risk of bacteraemia (RR: 1.38; 95% CI 0.23 to 8.23) and hospitalisation (RR: 0.87; 95% CI 0.3 to 2.55) was observed in corticosteroid group. CONCLUSION Moderate quality evidence suggests that short duration 'adjuvant corticosteroid therapy' along with routine antibiotic therapy in acute febrile urinary tract infection significantly reduces the risk of kidney scarring without any significant adverse effects.
Collapse
Affiliation(s)
- Jitendra Meena
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jogender Kumar
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
9
|
Azzolina D, Lorenzoni G, Bressan S, Da Dalt L, Baldi I, Gregori D. Handling Poor Accrual in Pediatric Trials: A Simulation Study Using a Bayesian Approach. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:2095. [PMID: 33669985 PMCID: PMC7924849 DOI: 10.3390/ijerph18042095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/11/2021] [Accepted: 02/13/2021] [Indexed: 02/05/2023]
Abstract
In the conduction of trials, a common situation is related to potential difficulties in recruiting the planned sample size as provided by the study design. A Bayesian analysis of such trials might provide a framework to combine prior evidence with current evidence, and it is an accepted approach by regulatory agencies. However, especially for small trials, the Bayesian inference may be severely conditioned by the prior choices. The Renal Scarring Urinary Infection (RESCUE) trial, a pediatric trial that was a candidate for early termination due to underrecruitment, served as a motivating example to investigate the effects of the prior choices on small trial inference. The trial outcomes were simulated by assuming 50 scenarios combining different sample sizes and true absolute risk reduction (ARR). The simulated data were analyzed via the Bayesian approach using 0%, 50%, and 100% discounting factors on the beta power prior. An informative inference (0% discounting) on small samples could generate data-insensitive results. Instead, the 50% discounting factor ensured that the probability of confirming the trial outcome was higher than 80%, but only for an ARR higher than 0.17. A suitable option to maintain data relevant to the trial inference is to define a discounting factor based on the prior parameters. Nevertheless, a sensitivity analysis of the prior choices is highly recommended.
Collapse
Affiliation(s)
- Danila Azzolina
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy; (D.A.); (G.L.); (I.B.)
- Department of Translational Medicine, University of Eastern Piedmont, 28100 Novara, Italy
| | - Giulia Lorenzoni
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy; (D.A.); (G.L.); (I.B.)
| | - Silvia Bressan
- Department of Women’s and Children’s Health, University of Padova, 35128 Padova, Italy; (S.B.); (L.D.D.)
| | - Liviana Da Dalt
- Department of Women’s and Children’s Health, University of Padova, 35128 Padova, Italy; (S.B.); (L.D.D.)
| | - Ileana Baldi
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy; (D.A.); (G.L.); (I.B.)
| | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy; (D.A.); (G.L.); (I.B.)
| |
Collapse
|
10
|
Da Dalt L, Bressan S, Scozzola F, Vidal E, Gennari M, La Scola C, Anselmi M, Miorin E, Zucchetta P, Azzolina D, Gregori D, Montini G. Oral steroids for reducing kidney scarring in young children with febrile urinary tract infections: the contribution of Bayesian analysis to a randomized trial not reaching its intended sample size. Pediatr Nephrol 2021; 36:3681-3692. [PMID: 34032923 PMCID: PMC8497283 DOI: 10.1007/s00467-021-05117-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 04/21/2021] [Accepted: 05/04/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND This study aimed to evaluate the effect of oral dexamethasone in reducing kidney scars in infants with a first febrile urinary tract infection (UTI). METHODS Children aged between 2 and 24 months with their first presumed UTI, at high risk for kidney scarring based on procalcitonin levels (≥1 ng/mL), were randomly assigned to receive dexamethasone in addition to routine care or routine care only. Kidney scars were identified by kidney scan at 6 months after initial UTI. Projections of enrollment and follow-up completion showed that the intended sample size could not be reached before funding and time to complete the study ran out. An amendment to the protocol was approved to conduct a Bayesian analysis. RESULTS We randomized 48 children, of whom 42 had a UTI and 18 had outcome kidney scans (instead of 128 planned). Kidney scars were found in 0/7 and 2/11 patients in the treatment and control groups respectively. The probability that dexamethasone could prevent kidney scarring was 99% in the setting of an informative prior probability distribution (which fully incorporated in the final inference the information on treatment effect provided by previous studies) and 98% in the low-informative scenario (which discounted the prior literature information by 50%). The probabilities that dexamethasone could reduce kidney scar formation by up to 20% were 61% and 53% in the informative and low-informative scenario, respectively. CONCLUSIONS Dexamethasone is highly likely to reduce kidney scarring, with a more than 50% probability to reduce kidney scars by up to 20%. TRIAL REGISTRATION NUMBER EudraCT number: 2013-000388-10; registered in 2013 (prospectively registered) A higher resolution version of the Graphical abstract is available as Supplementary information.
Collapse
Affiliation(s)
- Liviana Da Dalt
- Department of Women’s and Children’s Health, University of Padova, Via Giustiniani 4, 35128 Padova, Italy
| | - Silvia Bressan
- Department of Women's and Children's Health, University of Padova, Via Giustiniani 4, 35128, Padova, Italy.
| | | | - Enrico Vidal
- Department of Women’s and Children’s Health, University of Padova, Via Giustiniani 4, 35128 Padova, Italy ,Division of Pediatrics, Department of Medicine (DAME), University Hospital of Udine, Udine, Italy
| | - Monia Gennari
- Pediatric Emergency Unit, Department of Medical and Surgical Sciences (DIMEC), S. Orsola Hospital, Bologna, Italy
| | - Claudio La Scola
- Nephrology and Dialysis Unit, Department of Woman, Child and Urological Diseases, Azienda Ospedaliero-Universitaria Sant‘Orsola-Malpighi, Bologna, Italy
| | | | - Elisabetta Miorin
- Division of Pediatrics, Department of Medicine (DAME), University Hospital of Udine, Udine, Italy
| | - Pietro Zucchetta
- Nuclear Medicine Unit, Department of Medicine DIMED, University-Hospital of Padova, Padova, Italy
| | - Danila Azzolina
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Giovanni Montini
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca Granda, Ospedale Maggiore Policlinico, Milano, Italy ,Giuliana and Bernardo Caprotti Chair of Pediatrics, Department of Clinical Sciences and Community Health, University of Milano, Milano, Italy
| |
Collapse
|
11
|
Corticosteroids to prevent kidney scarring in children with a febrile urinary tract infection: a randomized trial. Pediatr Nephrol 2020; 35:2113-2120. [PMID: 32556960 PMCID: PMC7529851 DOI: 10.1007/s00467-020-04622-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/15/2020] [Accepted: 05/19/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND To evaluate the efficacy of adjuvant systemic corticosteroids in reducing kidney scarring. A previous study suggested that use of adjuvant systemic corticosteroids reduces kidney scarring in children radiologically confirmed to have extensive pyelonephritis. Efficacy of corticosteroids for children with febrile urinary tract infection (UTI) has not been studied. METHODS Children aged 2 months to 6 years with their first febrile UTI were randomized to corticosteroids or placebo for 3 days (both arms received antimicrobial therapy); kidney scarring was assessed using 99mTc-dimercaptosuccinic acid kidney scan 5-24 months after the initial UTI. RESULTS We randomized 546 children of which 385 had a UTI and 254 had outcome kidney scans (instead of the 320 planned). Rates of kidney scarring were 9.8% (12/123) and 16.8% (22/131) in the corticosteroid and placebo groups, respectively (p = 0.16), corresponding to an absolute risk reduction of 5.9% (95% confidence interval: - 2.2, 14.1). CONCLUSION While children randomized to adjuvant corticosteroids tended to develop fewer kidney scars than children who were randomized to receive placebo, a statistically significant difference was not achieved. However, the study was limited by not reaching its intended sample size. CLINICAL TRIAL REGISTRATION Clinicaltrials.gov , NCT01391793, Registered 7/12/2011 Graphical abstract.
Collapse
|
12
|
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.
Collapse
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
| |
Collapse
|
13
|
The pathogenesis and management of renal scarring in children with vesicoureteric reflux and pyelonephritis. Pediatr Nephrol 2020; 35:349-357. [PMID: 30847554 DOI: 10.1007/s00467-018-4187-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 12/11/2018] [Accepted: 12/20/2018] [Indexed: 10/27/2022]
Abstract
Bacterial urinary tract infections (UTIs) are one of the most common reasons for children to be admitted to hospital. Bacteria infect and invade the bladder (the lower urinary tract) and if the infection disseminates to the upper urinary tract, significant inflammation in the kidneys may arise. Inflammation is a double-edged sword: it is needed to clear bacteria, but if excessive, kidney tissue is injured. During injury, nephrons are destroyed and replaced with deposition of extracellular matrix and a renal scar. In this review, we explore the pathogenesis of UTIs and discuss the risk factors that result in dissemination of bladder infection to the kidneys. Three major risk factors predispose to kidney infections: the presence of vesicoureteric reflux, the presence of bladder and bowel dysfunction, and defects in the ability of the host immune response to clear bacteria. In this review, we will discuss these factors, their relationship to renal scarring, and potential treatments that might be beneficial to prevent renal scar formation in children.
Collapse
|
14
|
Ammenti A, Alberici I, Brugnara M, Chimenz R, Guarino S, La Manna A, La Scola C, Maringhini S, Marra G, Materassi M, Morello W, Nicolini G, Pennesi M, Pisanello L, Pugliese F, Scozzola F, Sica F, Toffolo A, Montini G. Updated Italian recommendations for the diagnosis, treatment and follow-up of the first febrile urinary tract infection in young children. Acta Paediatr 2020; 109:236-247. [PMID: 31454101 PMCID: PMC7004047 DOI: 10.1111/apa.14988] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 08/22/2019] [Accepted: 08/23/2019] [Indexed: 12/21/2022]
Abstract
AIM Our aim was to update the recommendations for the diagnosis, treatment and follow-up of the first febrile urinary tract infection in young children, which were endorsed in 2012 by the Italian Society of Pediatric Nephrology. METHODS The Italian recommendations were revised on the basis of a review of the literature published from 2012 to October 2018. We also carried out an ad hoc evaluation of the risk factors to identify children with high-grade vesicoureteral reflux or renal scarring, which were published in the previous recommendations. When evidence was not available, the working group held extensive discussions, during various meetings and through email exchanges. RESULTS Four major modifications have been introduced. The method for collecting urine for culture and its interpretation has been re-evaluated. We have reformulated the algorithm that guides clinical decisions to proceed with voiding cystourethrography. The suggested antibiotics have been revised, and we have recommended further restrictions of the use of antibiotic prophylaxis. CONCLUSION These updated recommendations have now been endorsed by the Italian Society of Pediatric Nephrology and the Italian Society for Pediatric Infectivology. They can also be used to compare other recommendations that are available, as a worldwide consensus in this area is still lacking.
Collapse
Affiliation(s)
- Anita Ammenti
- Pediatric Polyspecialistic GroupPoliambulatorio Medi‐SaluserParmaItaly
| | - Irene Alberici
- Department of Woman and Child's HealthUniversity of PadovaPadovaItaly
| | | | - Roberto Chimenz
- Pediatric Nephrology and Dialysis UnitDepartment of PediatricsG. Martino HospitalUniversity of MessinaMessinaItaly
| | - Stefano Guarino
- Department of WomanChild and of General and Specialized SurgeryUniversità degli Studi della Campania L. VanvitelliNaplesItaly
| | - Angela La Manna
- Department of WomanChild and of General and Specialized SurgeryUniversità degli Studi della Campania L. VanvitelliNaplesItaly
| | - Claudio La Scola
- Nephrology and Dialysis UnitDepartment of PediatricsAzienda Ospedaliero Universitaria Sant'Orsola‐MalpighiBolognaItaly
| | | | - Giuseppina Marra
- Pediatric NephrologyDialysis and Transplant UnitFondazione Ca'Granda, IRCCS Policlinico di MilanoMilanoItaly
| | | | - William Morello
- Pediatric NephrologyDialysis and Transplant UnitFondazione Ca'Granda, IRCCS Policlinico di MilanoMilanoItaly
| | | | - Marco Pennesi
- Department of PediatricsInstitute for Child and Maternal HealthIRCCS Burlo GarofoloTriesteItaly
| | | | | | | | | | | | - Giovanni Montini
- Pediatric NephrologyDialysis and Transplant UnitFondazione Ca'Granda, IRCCS Policlinico di MilanoMilanoItaly
- Giuliana and Bernardo Caprotti Chair of PediatricsDepartment of Clinical Sciences and Community HealthUniversity of MilanoMilanoItaly
| | | |
Collapse
|
15
|
Vazouras K, Basmaci R, Bielicki J, Folgori L, Zaoutis T, Sharland M, Hsia Y. Antibiotics and Cure Rates in Childhood Febrile Urinary Tract Infections in Clinical Trials: A Systematic Review and Meta-analysis. Drugs 2019; 78:1593-1604. [PMID: 30311096 DOI: 10.1007/s40265-018-0988-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE Urinary tract infections (UTIs) are common bacterial infections among children. OBJECTIVE To systematically review the antimicrobials used for febrile UTIs in paediatric clinical trials and meta-analyse the observed cure rates and reasons for treatment failure. MATERIALS AND METHODS We searched Medline, Embase and Cochrane central databases between January 1, 1990, and November 24, 2016, combining MeSH and free-text terms for: "urinary tract infections", AND "therapeutics", AND "clinical trials" in children (age range 0-18 years). Two independent reviewers assessed study quality and performed data extraction. The major outcome measures were clinical and microbiological cure rates according to different antibiotics. RESULTS We identified 2762 published studies and included 30 clinical trials investigating 3913 cases of paediatric febrile urinary tract infections. Children with no underlying condition were the main population included in the trials (n = 2602; 66.5%). Cephalosporins were the most frequent antibiotics studied in trials (22/30, 73.3%). Only a few antibiotics active against resistant UTIs have been tested in randomised clinical trials, mainly aminoglycosides. The average point cure rate of all investigational drugs was estimated to 95.3% (95% CI 93.5-96.9%). Among 3002 patients for whom cure and failure rates were reported, only 3.9% (3.9%; 118/3002) were considered clinically to have treatment failure, while 135 (4.5%; 135/3002) had microbiological failure. CONCLUSIONS We observed high treatment cure rates, regardless of the investigational drug chosen, the route of administration, duration and dosing. This suggests that future research should prioritise observational studies and clinical trials on children with multi-drug-resistant infections.
Collapse
Affiliation(s)
- Konstantinos Vazouras
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK. .,The Stavros Niarchos Foundation, Collaborative Center for Clinical Epidemiology and Outcomes Research (CLEO), University of Athens, Athens, Greece.
| | - Romain Basmaci
- Infection, Antimicrobiens, Modélisation, Evolution, Unité Mixte de Recherche 1137, Institut National de la Santé Et de la Recherche Médicale, Université Paris Diderot, Sorbonne Paris Cité, Paris, France.,Service de Pédiatrie-Urgences, Hôpital Louis-Mourier, Assistance Publique, Hôpitaux de Paris, 92700, Colombes, France
| | - Julia Bielicki
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK.,Paediatric Pharmacology, University Children's Hospital Basel, Basel, Switzerland
| | - Laura Folgori
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Theoklis Zaoutis
- The Stavros Niarchos Foundation, Collaborative Center for Clinical Epidemiology and Outcomes Research (CLEO), University of Athens, Athens, Greece.,Division of Infectious Diseases, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Yingfen Hsia
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| |
Collapse
|
16
|
Leung AK, Wong AH, Leung AA, Hon KL. Urinary Tract Infection in Children. RECENT PATENTS ON INFLAMMATION & ALLERGY DRUG DISCOVERY 2019; 13:2-18. [PMID: 30592257 PMCID: PMC6751349 DOI: 10.2174/1872213x13666181228154940] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 12/26/2018] [Accepted: 12/26/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Urinary Tract Infection (UTI) is a common infection in children. Prompt diagnosis and appropriate treatment are very important to reduce the morbidity associated with this condition. OBJECTIVE To provide an update on the evaluation, diagnosis, and treatment of urinary tract infection in children. METHODS A PubMed search was completed in clinical queries using the key terms "urinary tract infection", "pyelonephritis" OR "cystitis". The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. The search was restricted to English literature and the pediatric age group. Patents were searched using the key terms "urinary tract infection" "pyelonephritis" OR "cystitis" from www.google.com/patents, http://espacenet.com, and www.freepatentsonline.com. RESULTS Escherichia coli accounts for 80 to 90% of UTI in children. The symptoms and signs are nonspecific throughout infancy. Unexplained fever is the most common symptom of UTI during the first two years of life. After the second year of life, symptoms and signs of pyelonephritis include fever, chills, rigor, flank pain, and costovertebral angle tenderness. Lower tract symptoms and signs include suprapubic pain, dysuria, urinary frequency, urgency, cloudy urine, malodorous urine, and suprapubic tenderness. A urinalysis and urine culture should be performed when UTI is suspected. In the work-up of children with UTI, physicians must judiciously utilize imaging studies to minimize exposure of children to radiation. While waiting for the culture results, prompt antibiotic therapy is indicated for symptomatic UTI based on clinical findings and positive urinalysis to eradicate the infection and improve clinical outcome. The choice of antibiotics should take into consideration local data on antibiotic resistance patterns. Recent patents related to the management of UTI are discussed. CONCLUSION Currently, a second or third generation cephalosporin and amoxicillin-clavulanate are drugs of choice in the treatment of acute uncomplicated UTI. Parenteral antibiotic therapy is recommended for infants ≤ 2 months and any child who is toxic-looking, hemodynamically unstable, immunocompromised, unable to tolerate oral medication, or not responding to oral medication. A combination of intravenous ampicillin and intravenous/intramuscular gentamycin or a third-generation cephalosporin can be used in those situations. Routine antimicrobial prophylaxis is rarely justified, but continuous antimicrobial prophylaxis should be considered for children with frequent febrile UTI.
Collapse
Affiliation(s)
- Alexander K.C. Leung
- Address correspondence to this author at the Department of Pediatrics, the University of Calgary, Alberta Children’s Hospital, #200, 233 – 16th Avenue NW, Calgary, Alberta, Canada; Tel: (403) 230 3300; Fax: (403) 230 3322; E-mail:
| | | | | | | |
Collapse
|
17
|
Hong IK, Chung MH, Bin JH, Lee KY, Kim JS, Kim CH, Suh JS. Prediction of vesicoureteral reflux in children with febrile urinary tract infection using relative uptake and cortical defect in DMSA scan. Pediatr Neonatol 2018; 59:618-623. [PMID: 29576374 DOI: 10.1016/j.pedneo.2018.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 11/17/2017] [Accepted: 03/01/2018] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND Vesicoureteral reflux (VUR) is an important urologic anomaly that causes renal injury in children with febrile urinary tract infection (UTI). The present study aimed to evaluate the associations of abnormalities detected on technetium-99m-labeled dimercaptosuccinic acid (DMSA) scans, focusing on the association with VUR of the levels of relative decrease in kidney function and cortical defects after a first febrile UTI in children. METHODS All 171 children underwent ultrasonography, DMSA scan and voiding cystourethrography (VCUG). The features of ultrasound and DMSA scans were compared between patients with (n = 48) and without VUR (n = 123). The relative uptake (RU) by each kidney was derived from the absolute value of the differences between the value for RU of radionuclide in the right kidney and that in the left kidney. The extent of cortical defects (ECD) was graded according to the number of compartments that contained cortical defect in both kidneys (right upper/right lower, left upper/left lower). Receiver operating characteristic curves were constructed to examine the diagnostic value of these parameters of ultrasound and DMSA scans for predicting VUR. RESULTS The ratio of patients having hydronephrosis on ultrasound or cortical defects on DMSA scan did not differ significantly between VUR and non-VUR groups. However, the absolute values of the RU and the scores for ECD were significantly higher in the VUR group than in the non-VUR group. The area under the curves for these two parameters were higher than those for the presence of hydronephrosis or the presence of cortical defects or both. CONCLUSION Decreased relative function and increased extents of cortical defects on DMSA scan may be associated with the presence of VUR. These findings may assist pediatricians to decide whether febrile UTI children need to undergo VCUG.
Collapse
Affiliation(s)
- Il Ki Hong
- Department of Nuclear Medicine, Kyung Hee University Hospital, School of Medicine, Kyung Hee University, Seoul, Republic of Korea.
| | - Mi Hae Chung
- Department of Pediatrics, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Joong Hyun Bin
- Department of Pediatrics, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Kyung-Yil Lee
- Department of Pediatrics, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jung Sue Kim
- Department of Pediatrics, Cheongju St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chung Ho Kim
- Department of Nuclear Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jin-Soon Suh
- Department of Pediatrics, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| |
Collapse
|
18
|
Lashkar MO, Nahata MC. Antimicrobial Pharmacotherapy Management of Urinary Tract Infections in Pediatric Patients. J Pharm Technol 2018; 34:62-81. [PMID: 34860955 PMCID: PMC5998439 DOI: 10.1177/8755122518755402] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2024] Open
Abstract
Objective: To discuss the risk factors, microbial resistance rates, and pharmacotherapy, including antimicrobial choices and medication dosage regimens, for urinary tract infections (UTIs) in pediatric patients. Data Sources: A MEDLINE literature search (1985 to December 2017) was performed using the following keywords and associated medical subject headings: urinary tract infection, antimicrobial, treatment, and children. Study Selection and Data Extraction: Search was conducted to identify clinical trials, systematic reviews, and guidelines. Search was filtered to include studies with age range between birth and 18 years and published in English. Additional references were identified from selected review articles. Data Synthesis: In total, 27 studies investigating microbial resistance, 31 studies assessing antimicrobial efficacy, 34 studies describing prophylaxis, and 6 systematic reviews were included. The resistance patterns differed across age groups and affected the choice of empirical therapy. If pyelonephritis is suspected, empiric antimicrobials should have high urinary and sufficient parenchymal concentrations. Nitrofurantoin has low microbial resistance rates and can generally be used empirically for treating uncomplicated cystitis in children >1 month of age. Trimethoprim-sulfamethoxazole resistance has increased and should be avoided unless local susceptibility data are available. Certain patients with recurrent UTIs or renal abnormalities may require antimicrobial prophylaxis, which may be associated with adverse effects, such as intolerability or an increased risk of microbial resistance. Conclusion: The resistance pattern of uropathogens should be considered prior to initiating therapy. Controlled trials with large samples are needed to compare the treatment duration of various antimicrobial regimens and the specific role of prophylactic antimicrobials.
Collapse
|
19
|
Basmaci R, Vazouras K, Bielicki J, Folgori L, Hsia Y, Zaoutis T, Sharland M. Urinary Tract Infection Antibiotic Trial Study Design: A Systematic Review. Pediatrics 2017; 140:peds.2017-2209. [PMID: 29187579 DOI: 10.1542/peds.2017-2209] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/25/2017] [Indexed: 11/24/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Romain Basmaci
- Infection, Antimicrobiens, Modélisation, Evolution, Unité Mixte de Recherche 1137, Institut National de la Santé Et de la Recherche Médicale, Université Paris Diderot, Sorbonne Paris Cité, Paris, France.,Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's University of London, London, United Kingdom
| | - Konstantinos Vazouras
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's University of London, London, United Kingdom.,National School of Public Health, Athens, Greece
| | - Julia Bielicki
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's University of London, London, United Kingdom.,Paediatric Pharmacology, University Children's Hospital Basel, Basel, Switzerland; and
| | - Laura Folgori
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's University of London, London, United Kingdom
| | - Yingfen Hsia
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's University of London, London, United Kingdom
| | - Theoklis Zaoutis
- Department of Pediatrics, School of Medicine, University of Pennsylvania and Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's University of London, London, United Kingdom;
| |
Collapse
|
20
|
Slobodian EI, Kaladze NN, Govdaliuk AL, Kulik EI. [The nephroprotective potential of peloid therapy used for the rehabilitation of the patients presenting with chronic pyelonephritis]. VOPROSY KURORTOLOGII, FIZIOTERAPII, I LECHEBNOĬ FIZICHESKOĬ KULTURY 2017; 94:62-68. [PMID: 28884741 DOI: 10.17116/kurort201794362-68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This review article presents the data on the mechanism of action of peloid therapy from the perspective of its defibrosing effect, the structure and functions of the extracellular matrix under the normal and pathological conditions. In addition, role of this treatment modality in the progression of tubulointerstitial fibrosis which determines the severity and prognosis of chronic pyelonephritis is considered. The researchers are currently carry out the extensive studies aimed at the search of the methods for the primary and secondary prevention of chronic pyelonephritis. A wide range of pharmacotherapeutic modalities are currently used for this purpose. Moreover the development of long-acting anti-relapse medications is currently underway along with the further improvement of high-tech reconstructive surgical methods for the intervention on the organs of the urinary system. At the same time, the nephroprotective potential of the natural physical factors, such as therapeutic muds, e.g. peloids, remains poorly explored even though their well apparent thermophysical properties, unique organic and mineral composition, and saturation with biologically active compounds are well known long ago. The systemic response to peloid therapy manifests itself as the changes in the metabolism of the intercellular matrix and collagen of the connective tissue associated with the alterations in the process of fibrogenesis and the development of tubulointerstitial disorders. The direct and indirect influence of peloids on the connective tissue is possible. The indirect effects are attributable to the peloid impact on the antioxidant status, immunity, hormonal regulation, and metabolic processes. These findings suggest the necessity of the relevant experimental and clinical studies for the evaluation of the influence of peloid therapy on the structure and metabolism of the connective tissue in the kidneys including dynamics of the markers of inflammation, proliferation and fibrogenesis, and the hormonal status of the patients suffering from chronic pyelonephritis based on the application of the modern technologies in accordance with the requirements of evidence-based medicine.
Collapse
Affiliation(s)
- E I Slobodian
- S.I. Georgievsky Medical Academy, Federal state autonomous educational institution of higher professional education 'V.I. Vernadsky Crimean Federal University', Simferopol, Republic of Crimea, Russia, 295006
| | - N N Kaladze
- S.I. Georgievsky Medical Academy, Federal state autonomous educational institution of higher professional education 'V.I. Vernadsky Crimean Federal University', Simferopol, Republic of Crimea, Russia, 295006
| | - A L Govdaliuk
- S.I. Georgievsky Medical Academy, Federal state autonomous educational institution of higher professional education 'V.I. Vernadsky Crimean Federal University', Simferopol, Republic of Crimea, Russia, 295006
| | - E I Kulik
- S.I. Georgievsky Medical Academy, Federal state autonomous educational institution of higher professional education 'V.I. Vernadsky Crimean Federal University', Simferopol, Republic of Crimea, Russia, 295006
| |
Collapse
|
21
|
Abstract
The Xenopus genus includes several members of aquatic frogs native to Africa but is perhaps best known for the species Xenopus laevis and Xenopus tropicalis. These species were popularized as model organisms from as early as the 1800s and have been instrumental in expanding several biological fields including cell biology, environmental toxicology, regenerative biology, and developmental biology. In fact, much of what we know about the formation and maturation of the vertebrate renal system has been acquired by examining the intricate genetic and morphological patterns that epitomize nephrogenesis in Xenopus. From these numerous reports, we have learned that the process of kidney development is as unique among organs as it is conserved among vertebrates. While development of most organs involves increases in size at a single location, development of the kidney occurs through a series of three increasingly complex nephric structures that are temporally distinct from one another and which occupy discrete spatial locales within the body. These three renal systems all serve to provide homeostatic, osmoregulatory, and excretory functions in animals. Importantly, the kidneys in amphibians, such as Xenopus, are less complex and more easily accessed than those in mammals, and thus tadpoles and frogs provide useful models for understanding our own kidney development. Several descriptive and mechanistic studies conducted with the Xenopus model system have allowed us to elucidate the cellular and molecular mediators of renal patterning and have also laid the foundation for our current understanding of kidney repair mechanisms in vertebrates. While some species-specific responses to renal injury have been observed, we still recognize the advantage of the Xenopus system due to its distinctive similarity to mammalian wound healing, reparative, and regenerative responses. In addition, the first evidence of renal regeneration in an amphibian system was recently demonstrated in Xenopus laevis. As genetic and molecular tools continue to advance, our appreciation for and utilization of this amphibian model organism can only intensify and will certainly provide ample opportunities to further our understanding of renal development and repair.
Collapse
|
22
|
Abstract
Acute pyelonephritis is one of the most serious bacterial illnesses during childhood. Escherichia coli is responsible in most cases, however other organisms including Klebsiella, Enterococcus, Enterobacter, Proteus, and Pseudomonas species are being more frequently isolated. In infants, who are at major risk of complications such as sepsis and meningitis, symptoms are ambiguous and fever is not always useful in identifying those at high risk. A diagnosis of acute pyelonephritis is initially made on the basis of urinalysis; dipstick tests for nitrites and/or leukocyte esterase are the most accurate indicators of infection. Collecting a viable urine sample for urine culture using clean voided methods is feasible, even in young children. No gold standard antibiotic treatment exists. In children appearing well, oral therapy and outpatient care is possible. New guidelines suggest less aggressive imaging strategies after a first infection, reducing radiation exposure and costs. The efficacy of antibiotic prophylaxis in preventing recurrence is still a matter of debate and the risk of antibiotic resistance is a warning against its widespread use. Well-performed randomized controlled trials are required in order to better define both the imaging strategies and medical options aimed at preserving long-term renal function.
Collapse
|
23
|
Abstract
Pyelonephritis is an inflammatory process, and oxidative stress plays a major role in it. Anti-inflammatory or antioxidant therapy given concomitantly with antibiotics should lower the risk of postpyelonephritic scarring. As the lack of review studies in the use of antioxidants in urinary tract infections was detected, this study was designed. We conducted a review of available articles in PubMed and Google Scholar with a simple review, using keywords of “antioxidant” and “pyelonephritis” with all their possible synonyms and combinations. Only interventional studies were collected. There were neither limitations on time, nor the location of the study, type of subjects, administration rout of the antioxidant drug, and the antioxidant drug used. After studying the abstracts or in some cases the full text of articles, they were categorized based on the type of antioxidant, type and number of subjects, rout of administration, dosing, duration of treatment, year of publication of the paper, and the results. A total of 66 articles published from 1991 to 2015 were found by studying just the title of the papers. Studying the abstracts reduced this number to 51 studies. Antioxidants used for this condition were Vitamins A, E, and C, cytoflavin, caffeic acid phenethyl ester, ebselen, allopurinol, melatonin, N-acetylcysteine, oleuropein, montelukast, oxytocin, ozon, dapsone, pentoxifyllin, tadalafil, bilirubin, cranberry, meloxicam, L-carnitine, colchicine, perfluoran, methylprednisolone, and dexamethasone. Studies show that antioxidants are capable of reducing oxidative stress and can be used effectively along with antibiotics to reduce the scar formation.
Collapse
Affiliation(s)
- Zahra Allameh
- Department of Clinical Pharmacy and Pharmacy Practice, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Jamshid Salamzadeh
- Department of Clinical Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| |
Collapse
|
24
|
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.
Collapse
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
| | | |
Collapse
|
25
|
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.
Collapse
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
| | | |
Collapse
|
26
|
Steroids alone or as adjunctive therapy with doxycycline fail to improve oviduct damage in mice infected with Chlamydia muridarum. CLINICAL AND VACCINE IMMUNOLOGY : CVI 2014; 21:824-30. [PMID: 24695778 DOI: 10.1128/cvi.00006-14] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
In women, Chlamydia trachomatis can ascend from the cervix to the fallopian tubes, where an overly aggressive host inflammatory response can cause scarring that leads to chronic pelvic pain, infertility, or ectopic pregnancy. Although screening and treatment programs for women have resulted in decreased rates of sequelae, morbidities associated with oviduct scarring continue to occur. Since corticosteroids have anti-inflammatory and antifibrotic effects, we tested the ability of dexamethasone to inhibit inflammation and prevent oviduct scarring in mice genitally infected with Chlamydia muridarum. The administration of 1 or 2.5 mg/kg of body weight of dexamethasone on days 7 to 21 of infection resulted in reduced accumulation of inflammatory cells in the oviducts compared to that in controls. However, a concomitant increase in bacterial burden was observed, and chronic oviduct disease was not reduced. Adjunctive administration of a prolonged (21-day) or short (3-day) course of dexamethasone in combination with the antibiotic doxycycline also failed to reduce chronic oviduct pathology compared to antibiotic treatment alone. Steroids administered alone or adjunctively with antibiotics failed to prevent oviduct damage in this murine model of C. trachomatis infection.
Collapse
|
27
|
Bitsori M, Galanakis E. Pediatric urinary tract infections: diagnosis and treatment. Expert Rev Anti Infect Ther 2014. [DOI: 10.1586/eri.12.99] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
28
|
Renata Y, Jassar H, Katz R, Hochberg A, Nir RR, Klein-Kremer A. Urinary concentration of cytokines in children with acute pyelonephritis. Eur J Pediatr 2013; 172:769-74. [PMID: 23389820 DOI: 10.1007/s00431-012-1914-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Revised: 12/03/2012] [Accepted: 12/06/2012] [Indexed: 11/24/2022]
Abstract
Urinary tract infection (UTI) is a common bacterial infection among infants and children. Predicting which children with upper UTI will develop long-term sequelae remains difficult. We aimed at evaluating the predictive value of urine concentrations of interleukin-6 (UIL-6) and interleukin-8 (UIL-8) in subsequent renal scarring. In the current observational prospective study, urine samples for UIL-6 and UIL-8 were obtained from two groups: 31 children with first episode of febrile UTI and 22 febrile children of other origin. UIL-6 and UIL-8 were increased in children with febrile UTI, compared to children with fever of other origin [median and range (picograms per milliliter): (1) UIL-6, 74.46 (0-168) vs. 10.51 (0-47.50), respectively, p = 0.0001; (2) UIL-8, 2,660.38 (0-13,801) vs. 0, respectively, p = 0.0001]. Renal scarring was found in 5/31 (16 %) children with acute pyelonephritis. Initial median UIL-8 values were significantly higher in children with later renal scarring than in those without renal scarring [median and range (picograms per milliliter): 6,163 (2,021-13,801) vs. 1,490.5 (0-5,737), respectively, p = 0.018]. In conclusion, UIL-8 might serve as a predictive biomarker for renal scarring after an acute episode of pyelonephritis. Since UIL-8 emerges as a renal-specific diagnostic and prognostic marker, it may be suitable as a selective screening tool for children with febrile UTI.
Collapse
Affiliation(s)
- Yakubov Renata
- Pediatrics Department, Hillel Yaffe Medical Center, Hadera, P.O.B. 169, 38100, Israel
| | | | | | | | | | | |
Collapse
|
29
|
Abstract
PURPOSE OF REVIEW To review recent changes in the diagnostic and therapeutic approach to pediatric urinary tract infection in the emergency department. RECENT FINDINGS Updated guidelines from the American Academy of Pediatrics have significantly changed the approach to UTI, risk-stratifying patients according to their likelihood of UTI, and re-defining criteria for diagnosis of UTI. New studies have delineated important risk factors for concomitant bacteremia and adverse events. Procalcitonin has emerged as the inflammatory marker most predictive of upper versus lower urinary tract infection and renal scarring. Delays in empiric antibiotic therapy are associated with increased rates of renal scarring. Corticosteroids are a potential adjunctive therapy to antibiotics. SUMMARY Timely diagnosis and therapy of UTI are essential. New guidelines may alter the traditional approach to evaluation and management. Future studies will likely focus on the impact of the new guidelines, further delineate the role of procalcitonin in predicting UTI, and explore the role of corticosteroids as an adjunct to antibiotic therapy.
Collapse
|
30
|
Abstract
Pyelonephritis in childhood may, in the worst cases, lead to long-term cardiovascular morbidity due to tubulointerstitial renal scarring. Renal damage is the end result of an interplay between (1) urinary tract anatomy and function, (2) bacterial virulence factors, and (3) the host innate immune system, which on the one hand manages bacterial clearance, but on the other causes tubulointerstitial inflammation, which underlies the renal scarring. It is unclear how common postpyelonephritic scarring is, and how many of the "scars" in fact represent congenital renal hypoplasia. We do, however, know that some situations have an increased risk for scars, i.e., large renal-uptake defects on initial renal scintigraphy or pyelonephritis in young girls with dilating vesicoureteral reflux. It seems logical that antiinflammatory or antioxidant therapy given concomitantly with antibiotics should lower the risk of postpyelonephritic scarring. Animal studies give some support to this idea, but research on humans has been surprisingly scant. In this issue of Pediatric Nephrology, we publish a study that indicates that antioxidant therapy with vitamin A or E given to children with pyelonephritis may indeed lower the risk for renal scarring. This is a track that needs to be pursued further.
Collapse
|
31
|
Caine ST, Mclaughlin KA. Regeneration of functional pronephric proximal tubules after partial nephrectomy in Xenopus laevis. Dev Dyn 2013; 242:219-29. [PMID: 23233460 DOI: 10.1002/dvdy.23916] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Revised: 11/02/2012] [Accepted: 11/26/2012] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND While the renal system is critical for maintaining homeostatic equilibrium within the body, it is also susceptible to various kinds of damage. Tubule dysfunction in particular contributes to acute renal injury and chronic kidney disease in millions of patients worldwide. Because current treatments are highly invasive and often unavailable, gaining a better understanding of the regenerative capacity of renal structures is vital. Although the effects of various types of acute damage have been previously studied, the ability of the excretory system to repair itself after dramatic tissue loss due to mechanical damage is less well characterized. RESULTS A novel unilateral nephrectomy technique was developed to excise pronephric proximal tubules from Xenopus laevis tadpoles to study tubule repair after injury. Immunohistochemical detection of protein expression and renal uptake assays demonstrated that X. laevis larvae have the capacity to regenerate functional proximal tubules following resection. CONCLUSIONS We have validated the renal identity of the restored tubules and demonstrated their ability to functional normally providing the first evidence of regeneration of renal tissue in an amphibian system. Importantly, this tubule restoration occurs by means of a process involving an early apoptotic event and the biphasic expression of the matrix metalloproteinase, Xmmp-9.
Collapse
|
32
|
Ragnarsdóttir B, Svanborg C. Susceptibility to acute pyelonephritis or asymptomatic bacteriuria: host-pathogen interaction in urinary tract infections. Pediatr Nephrol 2012; 27:2017-2029. [PMID: 22327887 DOI: 10.1007/s00467-011-2089-1] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2011] [Revised: 11/30/2011] [Accepted: 12/02/2011] [Indexed: 10/14/2022]
Abstract
Our knowledge of the molecular mechanisms of urinary tract infection (UTI) pathogenesis has advanced greatly in recent years. In this review, we provide a general background of UTI pathogenesis, followed by an update on the mechanisms of UTI susceptibility, with a particular focus on genetic variation affecting innate immunity. The innate immune response of the host is critically important in the antibacterial defence mechanisms of the urinary tract, and bacterial clearance normally proceeds without sequelae. However, slight dysfunctions in these mechanisms may result in acute disease and tissue destruction. The symptoms of acute pyelonephritis are caused by the innate immune response, and inflammation in the urinary tract decreases renal tubular function and may give rise to renal scarring, especially in paediatric patients. In contrast, in children with asymptomatic bacteriuria (ABU), bacteria persist without causing symptoms or pathology. Pathogenic agents trigger a response determined by their virulence factors, mediating adherence to the urinary tract mucosa, signalling through Toll-like receptors (TLRs) and activating the defence mechanisms. In ABU strains, such virulence factors are mostly not expressed. However, the influence of the host on UTI severity cannot be overestimated, and rapid progress is being made in clarifying host susceptibility mechanisms. For example, genetic alterations that reduce TLR4 function are associated with ABU, while polymorphisms reducing IRF3 or CXCR1 expression are associated with acute pyelonephritis and an increased risk for renal scarring. It should be plausible to "individualize" diagnosis and therapy by combining information on bacterial virulence and the host response.
Collapse
Affiliation(s)
- Bryndís Ragnarsdóttir
- Institute of Laboratory Medicine, Section of Microbiology, Immunology and Glycobiology (MIG), Lund University, Sölvegatan 23, 22362, Lund, Sweden
| | - Catharina Svanborg
- Institute of Laboratory Medicine, Section of Microbiology, Immunology and Glycobiology (MIG), Lund University, Sölvegatan 23, 22362, Lund, Sweden.
| |
Collapse
|
33
|
Hewitt IK, Montini G. Pediatric febrile urinary tract infections: the current state of play. Ital J Pediatr 2011; 37:57. [PMID: 22128870 PMCID: PMC3269370 DOI: 10.1186/1824-7288-37-57] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Accepted: 11/30/2011] [Indexed: 11/29/2022] Open
Abstract
Studies undertaken in recent years have improved our understanding regarding the consequences and management of febrile urinary tract infections (UTIs), which are amongst the most common serious bacterial infections in childhood, with renal scarring a frequent outcome. In the past pyelonephritic scarring of the kidney, often associated with vesico-ureteral reflux (reflux nephropathy) was considered a frequent cause of chronic renal insufficiency in children. Increasing recognition as a consequence of improved antenatal ultrasound, that the majority of these children had congenital renal hypo-dysplasia, has resulted in a number of studies examining treatment strategies and outcomes following UTI. In recent years there is a developing consensus regarding the need for a less aggressive therapeutic approach with oral as opposed to intravenous antibiotics, and less invasive investigations, cystourethrography in particular, following an uncomplicated first febrile UTI. There does remain a concern that with this newer approach we may be missing a small subgroup of children more prone to develop severe kidney damage as a consequence of pyelonephritis, and in whom some form of intervention may prove beneficial. These concerns have meant that development of a universally accepted diagnostic protocol remains elusive.
Collapse
Affiliation(s)
- Ian K Hewitt
- Department of Pediatrics, Azienda Ospedaliero-Universitaria Sant'Orsola-Malpighi Bologna, Italy
| | | |
Collapse
|