Although the standard recommendation for treatment of acute pyelonephritis(APN) in young febrile children has been hospitalization for intravenous (IV) antimicrobials, the availability of potent oral antibiotics and interest in cost-containment prompted evaluation of the safety and effectiveness of outpatient therapy. In an ongoing study of oral vs. IV therapy for APN, febrile children aged 1-24 mos. diagnosed with UTI have been randomly assigned to receive either oral cefixime for 14 days, or initial IV cefotaxime for 3 days followed by oral cefixime for 11 additional days. Dimercaptosuccinic acid(DMSA) or glucoheptonate renal scans were performed at entry (to determine the proportion of patients with parenchymal inflammation) and again six mos. later(to determine the extent of renal scarring attributable to the index UTI). Renal scans at entry showed parenchymal inflammation in 137 (77%) of 179 patients, 111 (78%) of 142 aged 1-12 months and 26 (70%) of 37 aged 13-24 mos. Patients with abnormal compared with normal DMSA scans had significantly higher WBC (22.3 vs. 15.3 × 103/mm3, P<.01), ESR (43 vs. 24.6 mm/hr., P<.01), and CRP (9.7 vs. 2.9 mg/dL, P<.01). Most identified pathogens were E. coli, all of which were sensitive to 3rd generation cephalosporins. Nine patients had positive blood cultures; six were treated intravenously and three orally. Repeat urine cultures at 24 hrs. were sterile in all patients. Mean time to defervescence was 26.2 and 24.6 hours for orally and intravenously treated patients, respectively. Vesicoureteral reflux (VUR) was present in 75 (44%) of 172 patients who had a voiding cystourethrogram. Reinfections occurred in 10 of 90 intravenously treated patients. Of these, eight were symptomatic (fever and pyuria) and two were asymptomatic. In contrast, three of 83 orally treated patients had symptomatic and one had asymptomatic reinfections. Of the 11 patients with symptomatic reinfections, only five had VUR. Currently, 134 patients have completed the study; 90 (67%) scans were interpreted as normal and 44 (33%) showed renal scarring (<20% kidney area)--21 in the oral group and 23 in the IV group. No patients with initially normal renal scans had scarring at follow-up. These preliminary data suggest the equivalence of oral and IV treatment of APN in young febrile children. Because UTI is the most frequently occurring serious bacterial infection in young febrile children, large savings in health care expenditures are possible. Funded by Wyeth-Ayerst Laboratories.
