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ARTICLES: Ian K. Hewitt, Pietro Zucchetta, Luca Rigon, Francesca Maschio, Pier Paolo Molinari, Lisanna Tomasi, Antonella Toffolo, Luigi Pavanello, Carlo Crivellaro, Stefano Bellato, and Giovanni Montini Early Treatment of Acute Pyelonephritis in Children Fails to Reduce Renal Scarring: Data From the Italian Renal Infection Study Trials Pediatrics 2008; 122: 486-490 [Abstract] [Full text] [PDF]

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Early treatment of acute pyelonephritis is still mandatory

José Manuel Fernández-Menéndez, Carlos Pérez-Méndez   (4 September 2008)

Results needs to be qualified

vinay sharma, Partha Chatterjee MD   (5 November 2008)

Early treatment of acute pyelonephritis is still mandatory 4 September 2008
José Manuel Fernández-Menéndez, Pediatrician Department of Pediatrics. Hospital de Cabueñes, Gijón. Spain, Carlos Pérez-Méndez Send letter to journal: Re: Early treatment of acute pyelonephritis is still mandatory ihgjmfmdj{at}hotmail.com José Manuel Fernández-Menéndez, et al.	To the Editor We read with interest the study by Hewitt et al(1) on the effect of early treatment on the development of renal scarring in children with acute pyelonephritis (APN) . They find that early treatment of APN had no significant effect on the incidence of subsequent renal scarring and, therefore, find it “possible to advise a less-urgent approach for children with fever who appear otherwise well, even if there is a risk of recurrent urinary tract infection (UTI)”. In a previous study(2) involving 158 consecutive children with a first episode of symptomatic UTI we found that a delay in the start of treatment was an independent risk factor for the development of uptake defects in a dimercaptosuccinic acid (DMSA) scintigraphy performed in the acute phase of an episode of UTI (RR: 1.8; 95%CI: 1.34-2.41). Doganis et al(3) also showed that renal defects in the acute phase scan were more frequent when the institution of therapy was delayed, but that the frequency of late scarring in infants treated early and in those whose treatment was delayed did not differ, “suggesting that if the kidney is involved, the risk for development of scarring is independent of the timing of therapy”. We feel that, taking the results of the three studies together, one could conclude that early institution of therapy for febrile UTI is mandatory, since a delay in the start of treatment is associated with the development of abnormalities in the acute phase scan and, once they have occurred, the development of late renal scarring is less likely to be affected by therapy. José Manuel Fernández-Menéndez, Carlos Pérez-Méndez Servicio de Pediatría. Hospital de Cabueñes. Gijón. Spain REFERENCES 1. Hewitt IK, Zucchetta P, Rigon L , et al. Early treatment of acute pyelonephritis in children fails to reduce renal scarring: Data from the Italian Renal Infection Study Trials. Pediatrics. 2008;122: 486-490 2. Fernández-Menéndez JM, Málaga S, Matesanz JL, et al. Risk factors in the development of early technetium-99m dimercaptosuccinic acid renal scintigraphy lesions during first urinary tract infection in children. Acta Paediatr 2003; 92: 21-26 3. Doganis D, Siafas K, Mavrikou M, et al. Does early treatment of urinary tract infection prevent renal damage? Pediatrics. 2007; 120: e922- e928 Conflict of Interest: None declared
Results needs to be qualified 5 November 2008
vinay sharma, Resident Flushing Hospital Medical Center, NY, Partha Chatterjee MD Send letter to journal: Re: Results needs to be qualified drvnsharma{at}gmail.com vinay sharma, et al.	Dear Editor, Hewitt et al(1), have done a remarkable job by conducting this extensive study on the effect of early treatment on the development of renal scarring in children with acute pyelonephritis (APN) . However their conclusion that, early treatment of APN had no significant effect on the incidence of subsequent renal scarring needs to be qualified. Few questions still remained unanswered and they can really have an impact on outcome of this study Renal scarring has been closely linked to Vesicoureteral reflux (2,3). Though author mentioned that incidence of reflux was comparable in both study groups. It will be be of interest to know the exact incidence of Vesicoureteral reflux in renal scarring patients (n-89). Study says that patients were randomly allocated to two treatment groups. First received iv ceftriaxone for 3 days and later oral co-amoxyclav for 7 days while second group received 10 days of oral co-amoxyclav. It is possible that more sick children and infants were allocated to group which received iv cefriaxone initially. Though the inflammatory markers are comparable in groups but it is a possible bias on physician to give more urgent treatment to sick and infants which are at risk of renal scarring in future. References 1) Hewitt IK, Zucchetta P, Rigon L , et al. Early treatment of acute pyelonephritis in children fails to reduce renal scarring: Data from the Italian Renal Infection Study Trials. Pediatrics. 2008;122: 486-490 2) Mohanan N, Colhoun E, Puri P, Renal parenchymal damage in intermediate and high grade infantile vesicoureteral reflux. J Urol. 2008 Oct;180(4 Suppl):1635-8 3) Swerkersson S, Jodal U, Sixt R, Stokland E, Hansson S. Relationship among vesicoureteral reflux, urinary tract infection and renal damage in children. J Urol. 2007 Aug;178(2):647-51 Conflict of Interest: Results needs to be qualified