Shorter Course of Antibiotics Just as Effective for Kids With Pyelonephritis

By Lisa Rappaport

May 26, 2020

(Reuters Health) - Treating children with pyelonephritis with antibiotics for six to nine days may work just as well as treating them for 10 days or longer, a recent study suggests.

Researchers followed 791 children aged 6 months to 18 years who were treated with antibiotics for pyelonephritis between July 1, 2016, and October 1, 2018, at five hospitals in Maryland. This included 297 patients who were prescribed a shorter course of antibiotics of six to nine days (median 8 days) and 494 patients who were prescribed a longer course (median 11 days).

Within 30 days, a total of 79 children, or 10.1%, experienced treatment failure, defined as an unanticipated emergency room visit, outpatient visit, or hospital readmission for urinary tract infection symptoms; receipt of a prolonged course of antibiotics; or death.

The odds of treatment failure were similar for shorter and longer courses of antibiotics, at 11.2% and 9.4%, respectively (odds ratio 1.22), the study team reports in JAMA Network Open.

"Overall, this study should be good news for parents because it tells us that antibiotics courses of approximately one week are sufficient to adequately treat children with UTIs - even when they need to be hospitalized for the UTI," said Dr. Pranita Tamma, an associate professor of pediatrics in the Division of Infectious Diseases at Johns Hopkins University School of Medicine in Baltimore, a coauthor of the study.

"There will always be some children who have recurrent UTIs but we have no data to indicate that treating with a longer course of antibiotics will prevent this," Dr. Tamma said by email. "What we do know is that treating with a longer course of antibiotics will increase the risk of antibiotic-related side effects for children."

Ten patients (1.3%) were readmitted to the hospital for UTI symptoms, while 53 (6.8%) went to an outpatient clinic or the emergency room with UTI symptoms. In addition, 65 patients (8.3%) were prescribed more antibiotics as UTI symptoms continued beyond the initial course of treatment. One child (0.1%) died. These categories were not mutually exclusive.

When researchers looked at different age groups of children separately, they found no statistically significant differences in outcomes with shorter versus longer courses of antibiotics. Nor were there significant differences in outcomes based on the class of antibiotics prescribed.

However, more children aged 4 to 13 years experienced treatment failure (14.5%) than children aged 6 months to 3 years (7.4%) or children 14 to 18 years (7.8%).

The American Academy of Pediatrics recommends treating pyelonephritis for a range of 7 to 14 days.

Because the study was retrospective, it's possible that some children may have been prescribed longer courses of antibiotics than others for reasons that were not clear from the data.

"In a study like this, it is possible that the patients who received a longer course of antibiotics did so because they were judged to be more ill by the clinicians treating them," said Jason Gallagher, a clinical professor of pharmacy at Temple University in Philadelphia who wasn't involved in the study.

"The researchers took some steps to account for this in their analysis, but it is still possible," Gallagher said by email.

Even so, the results suggest that parents and clinicians should have an open discussion about what the appropriate duration of antibiotics might be when their child is diagnosed with pyelonephritis, said Dr. John David Spencer, an associate professor of pediatrics and chief of nephrology at Nationwide Children's Hospital and The Ohio State University College of Medicine in Columbus.

Parents should have an open dialogue with their pediatrician about how the diagnosis was made, accurate therapies, and treatment duration, Dr. Spencer, who wasn't involved in the study, said by email. It can take up to 48 hours after the diagnosis of pyelonephritis is made to determine the appropriate antibiotic.

"Risks of stopping therapy too soon may include worsening of symptoms, progressive infection leading to bacteremia or sepsis, recurrent infections, and/or kidney injury," Dr. Spencer said. "Prolonged therapy can promote antibiotic resistance, lead to GI upset, or change the composition of the gastrointestinal microbiome that may predispose the patient to subsequent or recurrent infections in the urinary tract or elsewhere."

SOURCE: JAMA Network Open, online May 4, 2020.