martes, octubre 14, 2008

Pielonefritis tratamiento

Summary and Comment

Myth Shattered About Early Treatment for Acute Pyelonephritis in Children
Early antibiotic treatment does not reduce renal scarring.


Renal scarring with subsequent hypertension and chronic renal failure are feared complications of acute pyelonephritis in infants and young children. The findings of this multicenter Italian study challenge the notion that delayed antibiotic treatment for pyelonephritis increases the risk for kidney damage.

Researchers assessed the association between duration of fever before antibiotic treatment and incidence of renal scarring at 1 year in children aged 1 month to 7 years who had a first episode of acute pyelonephritis and were enrolled in a trial that compared two antibiotic therapies (oral amoxicillin-clavulanate vs. parenteral ceftriaxone plus oral amoxicillin-clavulanate). The researchers selected 287 children for analysis who had normal prenatal renal ultrasound findings, positive technetium-99m-dimercaptosuccinic acid (DMSA) scans within 10 days after the start of treatment, and follow-up DMSA scans performed 12 months later. DMSA scans are the gold standard for diagnosing acute renal infection and renal scarring.

The incidence of renal scarring at 12 months did not differ significantly with progressive delay in initiation of antibiotic therapy from <1 day to 5 days after the onset of fever (odds ratio, 0.99). The results were similar when the analysis was restricted to children aged 1 month to 2 years, who are considered to be a group at particularly high risk (OR, 1.35). Severity of illness, total white blood cell counts, urine sterilization rates, time to resolution of fever, and antibiotic resistance rates also were similar between patients with and without renal scarring. Almost all infections were caused by Escherichia coli.

Comment: The prevailing opinion that delay in antibiotic therapy increases the risk for renal scarring was formed in the absence of good scientific evidence and has contributed to the urgency with which febrile children are referred to emergency departments to rule out urinary tract infection. Prompt antibiotic treatment is still appropriate when emergency physicians diagnose pyelonephritis, but we can assure parents that the presence of fever and infected urine for several days does not increase their child’s risk for renal damage.

— Jill M. Baren, MD, MBE, FACEP, FAAP

Published in Journal Watch Emergency Medicine October 10, 2008

Citation(s):

Hewitt IK et al. Early treatment of acute pyelonephritis in children fails to reduce renal scarring: Data from the Italian Renal Infection Study trials. Pediatrics 2008 Sep; 122:486.

Original article (Subscription may be required)

Medline abstract (Free)
Traducción: inglés » español
Summary and Comment

Myth Shattered About Early Treatment for Acute Pyelonephritis in Children
Early antibiotic treatment does not reduce renal scarring.


Renal scarring with subsequent hypertension and chronic renal failure are feared complications of acute pyelonephritis in infants and young children. The findings of this multicenter Italian study challenge the notion that delayed antibiotic treatment for pyelonephritis increases the risk for kidney damage.

Researchers assessed the association between duration of fever before antibiotic treatment and incidence of renal scarring at 1 year in children aged 1 month to 7 years who had a first episode of acute pyelonephritis and were enrolled in a trial that compared two antibiotic therapies (oral amoxicillin-clavulanate vs. parenteral ceftriaxone plus oral amoxicillin-clavulanate). The researchers selected 287 children for analysis who had normal prenatal renal ultrasound findings, positive technetium-99m-dimercaptosuccinic acid (DMSA) scans within 10 days after the start of treatment, and follow-up DMSA scans performed 12 months later. DMSA scans are the gold standard for diagnosing acute renal infection and renal scarring.

The incidence of renal scarring at 12 months did not differ significantly with progressive delay in initiation of antibiotic therapy from <1 day to 5 days after the onset of fever (odds ratio, 0.99). The results were similar when the analysis was restricted to children aged 1 month to 2 years, who are considered to be a group at particularly high risk (OR, 1.35). Severity of illness, total white blood cell counts, urine sterilization rates, time to resolution of fever, and antibiotic resistance rates also were similar between patients with and without renal scarring. Almost all infections were caused by Escherichia coli.

Comment: The prevailing opinion that delay in antibiotic therapy increases the risk for renal scarring was formed in the absence of good scientific evidence and has contributed to the urgency with which febrile children are referred to emergency departments to rule out urinary tract infection. Prompt antibiotic treatment is still appropriate when emergency physicians diagnose pyelonephritis, but we can assure parents that the presence of fever and infected urine for several days does not increase their child’s risk for renal damage.

— Jill M. Baren, MD, MBE, FACEP, FAAP

Published in Journal Watch Emergency Medicine October 10, 2008

Citation(s):

Hewitt IK et al. Early treatment of acute pyelonephritis in children fails to reduce renal scarring: Data from the Italian Renal Infection Study trials. Pediatrics 2008 Sep; 122:486.

Original article (Subscription may be required)

Medline abstract (Free) Resumen y comentario

Mito Shattered sobre el tratamiento temprano de la pielonefritis aguda en niños
Principios de tratamiento con antibióticos no reduce la cicatrización renal.


Cicatrización renal con la consiguiente hipertensión arterial y la insuficiencia renal crónica son de temer las complicaciones de la pielonefritis aguda en lactantes y niños de corta edad. Los resultados de este estudio multicéntrico italiano en tela de juicio la noción de que la demora en el tratamiento antibiótico para la pielonefritis aumenta el riesgo de daño renal.

Los investigadores evaluaron la asociación entre la duración de la fiebre antes del tratamiento antibiótico y la incidencia de cicatrices renales en 1 año en niños de edades comprendidas entre 1 mes a 7 años que había un primer episodio de pielonefritis aguda y se inscribieron en un ensayo que comparó dos tratamientos con antibióticos (amoxicilina oral - clavulánico frente a ceftriaxona parenteral y oral de amoxicilina-clavulánico). Los investigadores seleccionaron 287 niños para el análisis normal que la ecografía renal prenatal conclusiones, positivas tecnecio-99m-ácido dimercaptosuccinic (DMSA) explora un plazo de 10 días después del inicio del tratamiento y el seguimiento de DMSA exploraciones realizadas 12 meses más tarde. DMSA se analiza el patrón oro para el diagnóstico de insuficiencia renal aguda de la infección y la cicatrización renal.

La incidencia de cicatrices renales a los 12 meses no difirieron significativamente con el progresivo retraso en el inicio de la terapia antibiótica de <1 día a 5 días después de la aparición de la fiebre (odds ratio, 0,99). Los resultados fueron similares cuando el análisis se limitó a niños de edades comprendidas entre 1 mes a 2 años, que se consideran un grupo en particular de alto riesgo (OR: 1,35). Gravedad de la enfermedad, el total de glóbulos blancos, las tasas de esterilización de orina, el tiempo de la resolución de la fiebre, la resistencia a los antibióticos y las tasas también fueron similares entre los pacientes con insuficiencia renal y sin cicatrices. Casi todas las infecciones fueron causadas por Escherichia coli.

Comentario: La opinión prevaleciente que la demora en la terapia de antibióticos aumenta el riesgo de cicatrices renales se formó en la ausencia de buenas pruebas científicas y ha contribuido a la urgencia con la que los niños febriles se hace referencia a los departamentos de emergencia para descartar infección del tracto urinario. Símbolo del tratamiento antibiótico adecuado es todavía de emergencia cuando los médicos diagnosticar pielonefritis, pero podemos asegurar que los padres la presencia de fiebre y la infección de orina por varios días no aumentar su hijo el riesgo de daño renal.

- Jill M. Baren, MD, MBE, FACEP, FAAP

Publicado en el Diario Ciudadano de Emergencia de Medicina 10 de octubre de 2008

Visto (s):

Hewitt IK et al. El tratamiento temprano de la pielonefritis aguda en niños no para reducir la cicatrización renal: Los datos de la infección renal italiano Estudio de los juicios. Pediatría 2008 Sep; 122:486.

Artículo original (Suscripción puede ser necesario)

Resumen Medline (Gratis)
Traducción: inglés » español
Summary and Comment