Pediatric Pyelonephritis

Maria G. Tanzi, PharmD

A short course (6 to 9 days) of antibiotics has been shown to be as effective as the standard prolonged course (10 or more days) for treatment of pyelonephritis in children. The shorter course of antibiotics may also mitigate the risk of future drug-resistant urinary tract infections (UTIs), according to data from an observational study published on May 4 in JAMA Network Open.   

“Although pyelonephritis is relatively common in the pediatric population, we don’t have data on how long UTIs should be treated in children,” Pranita Tamma, MD, MHS, associate professor of pediatrics, division of infectious diseases at Johns Hopkins University School of Medicine, and study author, told Pharmacy Today.

 “The American Academy of Pediatrics recommends treating pyelonephritis in the range of 7 to 14 days since there are a lack of data to narrow this interval in children. However, there is a growing body of evidence in the medical literature that every additional day antibiotics are consumed is not without consequence such as allergic reactions, bad rashes, diarrhea, inconvenience for patients and families, and the risk of future drug-resistant UTIs that can be more and more challenging to treat.”

Observational data  

Tamma and colleagues conducted a retrospective observational study assessing data from five hospitals in Maryland between July 1, 2016, and October 1, 2018. Eligible participants were children aged 6 months to 18 years who presented to one of the medical centers with urinary cultures growing Escherichia coli, Klebsiella pneumoniae, Klebsiella oxytoca, or Proteus mirabilis, and had laboratory and clinical criteria for pyelonephritis.

Of 791 children who met study eligibility criteria (mean age 9.2 years, 85% girls), 297 were prescribed a short course (6­–9 days, median duration 8 days) and 494 were prescribed a prolonged course (10 or more days, median duration 11 days) of antibiotics for pyelonephritis.

The data showed that the odds of treatment failure were similar for the two groups, with 11.2% for the short-course compared with 9.4% for the prolonged course. Also, there was no significant difference in the odds of a drug-resistant uropathogen for patients with a subsequent UTI within 30 days, but the numbers were lower for short-course therapy versus a prolonged course (40% vs. 64%).

Why are clinicians giving children longer courses than adults?  

There have been a number of clinical trials in the adult population showing that antibiotic courses of approximately a week are sufficient for the treatment of pyelonephritis.

Tamma noted that despite these data, most pediatricians prescribe more than 7 days of antibiotics for pyelonephritis. She highlighted several reasons for this, such as a lack of awareness of the data and pediatricians being reluctant to apply data from the adult population because they perceive children to be “different” than adults.

“There is no evidence demonstrating that children need longer than a week of antibiotics to treat a UTI, and there is no reason to think that children should have different treatment outcomes than adults enrolled in published UTI clinical trials,” said Tamma.

She also described a third fear of “rocking the boat” if it has become common practice to treat certain infections with certain durations of therapy. It may be difficult to deviate from the perceived common practice if they are generally expected by parents and colleagues.

Counseling parents and caregivers    

The current data should be good news for parents and caregivers as it suggests that antibiotic courses of approximately one week are sufficient to adequately treat children with UTIs. As noted above, longer courses of antibiotics are associated with adverse events, so minimizing these risks is essential.

“Whenever a patient, whether a child or adult, is being prescribed an antibiotic, they should feel comfortable asking the clinician a few questions—why that particular antibiotic was selected, how does he/she know that the duration of therapy being prescribed is the right duration, and what are the expected common side effects,” Tamma told Today.

Pharmacists can play an active role in screening for allergies, as well as educating patients on proper dosage and administration, the importance of completing the prescribed course of therapy, and how to mitigate more common adverse events (e.g., taking select antibiotics with food). 

“We are hopeful that the findings of this work will encourage pharmacists and physicians to feel confident in recommending no longer than 7 days of antibiotic therapy for most children with pyelonephritis,” Tamma concluded.