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Three Part Question

Why do medics use [IV antibiotics] to [manage children with pyelonephritis] when [oral antibiotics] are just as [effective]?

Clinical Scenario

10 year girl present in A&E with 2 day history of fever, right sided back pain and dysuria. She had urine dip done which showed 3+ leucocytes, 1+ blood and nitrates positive. The registrar seeing the patient wants her to be immediately started on IV antibiotics for suspected pyelonephritis. The SHO questions why is IV required when the patient can tolerate oral?

Search Strategy

Cochrane library and pubmed was searched in January 2021
using the terms “pyelonephritis”, “children”, “oral antibiotics” and “intravenous antibiotics”.

Search Outcome

Cochrane library yielded 12 results, 2 of which were review articles.
Pubmed using same terms, yielded 10 results, 3 of which were useful.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Bocquet et al 30/01/2012 United States of America	Multicentre from 10 pediatric units 171 infants and children aged 1 to 36 months with first episode of pyelonephritis	Prospective study	evidence of renal scarring	incidence of renal scarring in oral antibiotic children was 30.8% compared to those children who had IV antibiotics which was 27.3%
Hoberman et al 1999 United States of America	Multicentre 306 children with fever and UTI	Prospective	sterilization of urine	all cultures were sterile at 24 hours
			defervescence	25 hours for those that took oral antibiotics and 24 hours for those that took IV antibiotics
			symptomatic reinfection	4.6% of those who had oral antibiotics had reinfection compared to 7.2% of those who had IV antibiotics
			renal scarring	at 6 months, 9.8% of those with oral antibiotics had renal scarring compared to the patient which was given IV antibiotics which was 7.2%
Neuhaus et al 2008 Switzerland	Patients from 5 Swiss pediatric hospitals 365 children with bacteria in urine and acute lesions on DMSA	Multicentre prospective	evidence of renal scarring	no significant difference between renal scarring in both groups (p=0.2) after taking into account confounding variables

Comment(s)

Patients who have pyelonephritis should have a trial with oral antibiotics if they are able to tolerate it and their clinical state doesn't go against NICE guidance. There is a mentality among medics that IV antibiotics are stronger and therefore more effective in treating such conditions. But if evidence support that there isn't a difference in the outcome, shouldn't oral antibiotics be one of our first thoughts to reduce hospital admissions and improve overall patient experience. I am not saying that this is something that will be the case for all patients but I definitely think it is something that we should be aware of and willing to consider.

Clinical Bottom Line

Oral antibiotics can be used as initial management for children with pyelonephritis

Level of Evidence

Level 3 - Small numbers of small studies or great heterogeneity or very different population.

References

1. Nathalie Bocquet, Aline Sergent Alaoui, Jean-Pierre Jais, Vincent Gajdos, Vincent Guigonis, Bernard Lacour and Gerard Cheron Randomized trial of oral versus sequential IV/oral antibiotic for acute pyelonephritis in children Pediatrics February 2012, 129 (2) e269-e275
2. Hoberman, Alejandro M.D; Wald, Ellen R. M.D Treatment of Urinary Tract Infections The Pediatric Infectious Disease Journal November 1999 - Volume 18 - Issue 11- p 1020-10121
3. Thomas J Neuhaus, Christoph Berger, Katja Buechner, Paloma Parvex, Gian Bischoff, Philippe Goetschel, Daniela Husarik, Ulrich Wili, Luciano Molinari, Christoph Rudin, Alain Gervaix, Urs Hunziker,et al Randomised trial of oral versus sequential intravenous/oral cephalosporins in children with pyelonephritis European Journal of Pediatrics 2008, 167, 1037-1047