Montini G et al. (2007) Antibiotic treatment for pyelonephritis in children: multicentre randomised controlled non-inferiority trial. BMJ [doi:10.1136/bmj.39244.692442.55]

Current guidelines recommend that children with acute pyelonephritis are initially treated with a parenteral third-generation cephalosporin such as ceftriaxone, and then oral antibiotics. A recent noninferiority trial has found, however, that oral antibiotics alone are just as effective as the recommended regime, a finding that will potentially lower costs and reduce the discomfort of children with pyelonephritis.

The randomized controlled trial recruited 502 children (aged 1 month to 7 years) with a first episode of acute pyelonephritis from 28 pediatric units across northeast Italy. Children were randomized to either parenteral ceftriaxone 50 mg/kg/day for 3 days followed by oral co-amoxiclav 50 mg/kg/day for 7 days (n = 258), or to co-amoxiclav 50 mg/kg/day for 10 days (n = 244).

The rates of scintigraphy-detected renal scarring at 12 months (examined in 400 children) were similar in patients who had received parenteral ceftriaxone plus oral co-amoxiclav and in those who had received oral co-amoxiclav only (17.7% and 13.7%, respectively). Secondary outcomes, which assessed the efficacy of antibiotic treatment in the short term (i.e. reduction in inflammatory indices, percentage of patients with sterile urine 72 h after treatment initiation, and time to fever subsidence) were also similar in the two groups. After 3 days of treatment, urine cultures collected from 388 of 390 patients were negative; two cases (one in each treatment group) were positive for Pseudomonas aeruginosa. Minor adverse effects (mostly diarrhea or vomiting) occurred in 15 children who received initial treatment with co-amoxiclav; three patients experienced minor adverse effects with ceftriaxone.