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PEDIATRICS Vol. 104 No. 1 July 1999, pp. 79-86

Oral Versus Initial Intravenous Therapy for Urinary Tract Infections in Young Febrile Children

Received Sep 2, 1998; accepted Feb 1, 1999.

Alejandro Hoberman*, Ellen R. Wald*, Robert W. Hickey*, Dagger , Marc Baskin§, Martin Charronparallel , Massoud Majd, Diana H. Kearney*, Ellen A. Reynolds*, Jerry Ruley#, and Janine E. Janosky**

From the Departments of * Pediatrics, parallel  Radiology, and ** Family Medicine and Clinical Epidemiology, University of Pittsburgh School of Medicine and Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania; the Dagger  Department of Pediatrics, Ohio State University, and Columbus Children's Hospital, Columbus, Ohio; the § Department of Pediatrics, Harvard School of Medicine, and Children's Hospital, Boston, Massachusetts; the  Department of Radiology (Nuclear Medicine), George Washington University Medical Center, and Children's National Medical Center, Washington, DC; and the # Pediatric Kidney Center, Fairfax Hospital for Children, Fairfax, Virginia.

Background.  The standard recommendation for treatment of young, febrile children with urinary tract infection has been hospitalization for intravenous antimicrobials. The availability of potent, oral, third-generation cephalosporins as well as interest in cost containment and avoidance of nosocomial risks prompted evaluation of the safety and efficacy of outpatient therapy.

Methods.  In a multicenter, randomized clinical trial, we evaluated the efficacy of oral versus initial intravenous therapy in 306 children 1 to 24 months old with fever and urinary tract infection, in terms of short-term clinical outcomes (sterilization of the urine and defervescence) and long-term morbidity (incidence of reinfection and incidence and extent of renal scarring documented at 6 months by 99mTc-dimercaptosuccinic acid renal scans). Children received either oral cefixime for 14 days (double dose on day 1) or initial intravenous cefotaxime for 3 days followed by oral cefixime for 11 days.

Results.  Treatment groups were comparable regarding demographic, clinical, and laboratory characteristics. Bacteremia was present in 3.4% of children treated orally and 5.3% of children treated intravenously. Of the short-term outcomes, 1) repeat urine cultures were sterile within 24 hours in all children, and 2) mean time to defervescence was 25 and 24 hours for children treated orally and intravenously, respectively. Of the long-term outcomes, 1) symptomatic reinfections occurred in 4.6% of children treated orally and 7.2% of children treated intravenously, 2) renal scarring at 6 months was noted in 9.8% children treated orally versus 7.2% of children treated intravenously, and 3) mean extent of scarring was ~8% in both treatment groups. Mean costs were at least twofold higher for children treated intravenously ($3577 vs $1473) compared with those treated orally.

Conclusions.  Oral cefixime can be recommended as a safe and effective treatment for children with fever and urinary tract infection. Use of cefixime will result in substantial reductions of health care expenditures.  Key words:  urinary tract infection, acute pyelonephritis, therapy.




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