Randomized Trial of Oral Versus Sequential IV/Oral Antibiotic for Acute Pyelonephritis in Children

OBJECTIVE: To confirm whether oral antibiotic treatment is as efficacious as sequential intravenous/oral antibiotic treatment in the prevention of renal scarringin children with acute pyelonephritis and scintigraphy-documented acute lesions. METHODS: In a prospective multicenter trial, children aged 1 to 36 months with their first case of acute pyelonephritis, a serum procalcitoninconcentration ≥0.5 ng/mL, no known uropathy, and a normal ultrasound exam were randomized into 2 treatment groups. They received either oral cefixime for 10 days or intravenous ceftriaxone for 4 days followed by oral cefixime for 6 days. Patients with acute renal lesions detected on early dimercaptosuccinic acid scintigraphyunderwent a follow-up scintigraphy6 to 8 months later. RESULTS: The study included 171 infants and children. There were no significant differences between the 2 groups in any clinical characteristic. Initial scintigraphyresults were abnormal for 119 children. Ninety-six children were measured for renal scarringat the follow-up scintigraphy(per protocol analysispopulation). The incidence of renal scarringwas 30.8% in the oral treatment group and 27.3% for children who received the sequential treatment. CONCLUSIONS: Although this trial does not statistically demonstrate the noninferiority of oral treatment compared with the sequential treatment, our study confirmed the results of previously published reports and therefore supports the use of an oral antibiotic treatment of primary episodes of acute pyelonephritis in infants and young children. * Abbreviations: APN — : acute pyelonephritis CI — : confidence interval DMSA — : dimercaptosuccinic acidED — : emergency department ITT — : intention to treat PCT — : procalcitoninPPA — : per protocol analysisUTIs — : urinary tract infections VCG — : voiding cystographyVUR — : vesicoureteral reflux