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Do All Children with Pyelonephritis Require Hospital Admission?

Treatment with oral antibiotics alone is as effective as standard treatment with parenteral antibiotics followed by oral antibiotics.

Risk for sepsis and long-term renal scarring has led some authorities to recommend inpatient treatment with parenteral antibiotics for young children in whom pyelonephritis is suspected. In a multicenter open-label study, investigators in Italy randomized 502 children (age range, 1 month to 7 years) with pyelonephritis to receive either oral amoxicillin plus clavulanic acid (50 mg/kg amoxicillin in 3 divided doses daily) for 10 days or standard treatment with parenteral ceftriaxone (50 mg/kg in a single daily dose) for 3 days followed by oral amoxicillin plus clavulanic acid (50 mg/kg in 3 divided doses daily) for 7 days. All participants were admitted to the hospital until defervescence or for at least 3 days. Children with severe sepsis, dehydration, vomiting, or history of pyelonephritis or abnormal ultrasound were excluded.

About 20% of patients were lost to follow-up by 12 months. Among the remaining participants, the incidence of scarring as detected by scintigraphy did not differ significantly between the group that received standard treatment and the group that received oral treatment only (17.7% and 13.7%). Secondary outcomes — time to fever reduction, amount of reduction in inflammatory indices, and percentage of patients with sterile urine after 72 hours — also were similar in the two groups. Escherichia coli was identified as the pathogen in 94.4% of positive urine cultures.

Comment: This study suggests that children with first-time urinary tract infections with fever who are otherwise healthy, clinically stable, and not vomiting can be treated as outpatients, provided that local antibiotic sensitivities are considered, caretakers are reliable, and close follow-up can be arranged.

— Kristi L. Koenig, MD, FACEP

Published in Journal Watch Emergency Medicine September 14, 2007

Citation(s):

Montini G et al. Antibiotic treatment for pyelonephritis in children: Multicentre randomised controlled non-inferiority trial. BMJ 2007 Aug 25; 335:386.

• Original article (Subscription may be required)
• Medline abstract (Free)

Watson AR. Management of urinary tract infection in children. BMJ 2007 Aug 25; 335:356.

• Original article (Subscription may be required)
• Medline abstract (Free)