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Randomised trial of oral versus sequential intravenous/oral cephalosporins in children with pyelonephritis

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Abstract

The hypothesis was tested that oral antibiotic treatment in children with acute pyelonephritis and scintigraphy-documented lesions is equally as efficacious as sequential intravenous/oral therapy with respect to the incidence of renal scarring. A randomised multi-centre trial was conducted in 365 children aged 6 months to 16 years with bacterial growth in cultures from urine collected by catheter. The children were assigned to receive either oral ceftibuten (9 mg/kg once daily) for 14 days or intravenous ceftriaxone (50 mg/kg once daily) for 3 days followed by oral ceftibuten for 11 days. Only patients with lesions detected on acute-phase dimercaptosuccinic acid (DMSA) scintigraphy underwent follow-up scintigraphy. Efficacy was evaluated by the rate of renal scarring after 6 months on follow-up scintigraphy. Of 219 children with lesions on acute-phase scintigraphy, 152 completed the study; 80 (72 females, median age 2.2 years) were given ceftibuten and 72 (62 females, median age 1.6 years) were given ceftriaxone/ceftibuten. Patients in the intravenous/oral group had significantly higher C-reactive protein (CRP) concentrations at baseline and larger lesion(s) on acute-phase scintigraphy. Follow-up scintigraphy showed renal scarring in 21/80 children treated with ceftibuten and 33/72 with ceftriaxone/ceftibuten (p = 0.01). However, after adjustment for the confounding variables (CRP and size of acute-phase lesion), no significant difference was observed for renal scarring between the two groups (p = 0.2). Renal scarring correlated with the extent of the acute-phase lesion (r = 0.60, p < 0.0001) and the grade of vesico-ureteric reflux (r = 0.31, p = 0.03), and was more frequent in refluxing renal units (p = 0.04). The majority of patients, i.e. 44 in the oral group and 47 in the intravenous/oral group, were managed as out-patients. Side effects were not observed. From this study, we can conclude that once-daily oral ceftibuten for 14 days yielded comparable results to sequential ceftriaxone/ceftibuten treatment in children aged 6 months to 16 years with DMSA-documented acute pyelonephritis and it allowed out-patient management in the majority of these children.

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Abbreviations

CRP:

C-reactive protein

DMSA:

Dimercaptosuccinic acid

VUR:

Vesico-ureteric reflux

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Authors and Affiliations

  1. Department of Nephrology, University Children’s Hospital Zurich, Steinwiesstrasse 75, 8032, Zurich, Switzerland

    Thomas J. Neuhaus

  2. Department of General Paediatrics, University Children’s Hospital Zurich, Steinwiesstrasse 75, 8032, Zurich, Switzerland

    Thomas J. Neuhaus & Sergio Stocker

  3. Department of Infectious Diseases, University Children’s Hospital Zurich, Steinwiesstrasse 75, 8032, Zurich, Switzerland

    Christoph Berger, Katja Buechner & David Nadal

  4. Department of Radiology, University Children’s Hospital Zurich, Steinwiesstrasse 75, 8032, Zurich, Switzerland

    Ulrich Willi

  5. Child Development Center, University Children’s Hospital Zurich, Steinwiesstrasse 75, 8032, Zurich, Switzerland

    Luciano Molinari

  6. Department of Nephrology, University Children’s Hospital Geneva, 1211, Geneva 14, Switzerland

    Paloma Parvex, Alain Gervaix & Eric Girardin

  7. Department of Paediatrics, Cantonal Hospital Winterthur, 8400, Winterthur, Switzerland

    Gian Bischoff & Urs Hunziker

  8. Department of Paediatrics, City Hospital Zurich-Triemli, 8063, Zurich, Switzerland

    Philippe Goetschel

  9. Department of Nuclear Medicine, University Hospital Zurich, 8091, Zurich, Switzerland

    Daniela Husarik

  10. Department of Nephrology, University Children’s Hospital Basle, 4005, Basle, Switzerland

    Christoph Rudin

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  1. Thomas J. Neuhaus
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  2. Christoph Berger
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  4. Paloma Parvex
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  8. Ulrich Willi
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  13. Sergio Stocker
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  14. Eric Girardin
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  15. David Nadal
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Corresponding author

Correspondence to David Nadal.

Additional information

TJN, CB and KB contributed equally to this work. EG and DN share senior authorship.

Trial number: Register of the Swiss national agency for therapeutic products (Swissmedic).Reference number: IKS 2001S03204

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Neuhaus, T.J., Berger, C., Buechner, K. et al. Randomised trial of oral versus sequential intravenous/oral cephalosporins in children with pyelonephritis. Eur J Pediatr 167, 1037–1047 (2008). https://doi.org/10.1007/s00431-007-0638-1

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  • DOI: https://doi.org/10.1007/s00431-007-0638-1

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