Why do people use IV antibiotics when oral are just as good?
Date First Published:
January 27, 2021
Last Updated:
July 29, 2021
Report by:
Antoniece Duncanson, Paediatric SHO (Health Education England North East)
Three-Part Question:
Why do medics use [IV antibiotics] to [manage children with pyelonephritis] when [oral antibiotics] are just as [effective]?
Clinical Scenario:
10 year girl present in A&E with 2 day history of fever, right sided back pain and dysuria. She had urine dip done which showed 3+ leucocytes, 1+ blood and nitrates positive. The registrar seeing the patient wants her to be immediately started on IV antibiotics for suspected pyelonephritis. The SHO questions why is IV required when the patient can tolerate oral?
Search Strategy:
Cochrane library and pubmed was searched in January 2021
Search Details:
using the terms “pyelonephritis”, “children”, “oral antibiotics” and “intravenous antibiotics”.
Outcome:
Cochrane library yielded 12 results, 2 of which were review articles.
Pubmed using same terms, yielded 10 results, 3 of which were useful.
Pubmed using same terms, yielded 10 results, 3 of which were useful.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Randomized trial of oral versus sequential IV/oral antibiotic for acute pyelonephritis in children Nathalie Bocquet, Aline Sergent Alaoui, Jean-Pierre Jais, Vincent Gajdos, Vincent Guigonis, Bernard Lacour and Gerard Cheron 30/01/2012 United States of America | Multicentre from 10 pediatric units 171 infants and children aged 1 to 36 months with first episode of pyelonephritis |
Prospective study | evidence of renal scarring | incidence of renal scarring in oral antibiotic children was 30.8% compared to those children who had IV antibiotics which was 27.3% | |
| Treatment of Urinary Tract Infections Hoberman, Alejandro M.D; Wald, Ellen R. M.D 1999 United States of America | Multicentre 306 children with fever and UTI |
Prospective | sterilization of urine | all cultures were sterile at 24 hours | |
| defervescence | 25 hours for those that took oral antibiotics and 24 hours for those that took IV antibiotics | ||||
| symptomatic reinfection | 4.6% of those who had oral antibiotics had reinfection compared to 7.2% of those who had IV antibiotics | ||||
| renal scarring | at 6 months, 9.8% of those with oral antibiotics had renal scarring compared to the patient which was given IV antibiotics which was 7.2% | ||||
| Randomised trial of oral versus sequential intravenous/oral cephalosporins in children with pyelonephritis Thomas J Neuhaus, Christoph Berger, Katja Buechner, Paloma Parvex, Gian Bischoff, Philippe Goetschel, Daniela Husarik, Ulrich Wili, Luciano Molinari, Christoph Rudin, Alain Gervaix, Urs Hunziker,et al 2008 Switzerland | Patients from 5 Swiss pediatric hospitals 365 children with bacteria in urine and acute lesions on DMSA |
Multicentre prospective | evidence of renal scarring | no significant difference between renal scarring in both groups (p=0.2) after taking into account confounding variables |
Author Commentary:
Patients who have pyelonephritis should have a trial with oral antibiotics if they are able to tolerate it and their clinical state doesn't go against NICE guidance. There is a mentality among medics that IV antibiotics are stronger and therefore more effective in treating such conditions. But if evidence support that there isn't a difference in the outcome, shouldn't oral antibiotics be one of our first thoughts to reduce hospital admissions and improve overall patient experience. I am not saying that this is something that will be the case for all patients but I definitely think it is something that we should be aware of and willing to consider.
Bottom Line:
Oral antibiotics can be used as initial management for children with pyelonephritis
Level of Evidence:
Level 3: Small numbers of small studies or great heterogeneity or very different population
References:
- Nathalie Bocquet, Aline Sergent Alaoui, Jean-Pierre Jais, Vincent Gajdos, Vincent Guigonis, Bernard Lacour and Gerard Cheron. Randomized trial of oral versus sequential IV/oral antibiotic for acute pyelonephritis in children
- Hoberman, Alejandro M.D; Wald, Ellen R. M.D. Treatment of Urinary Tract Infections
- Thomas J Neuhaus, Christoph Berger, Katja Buechner, Paloma Parvex, Gian Bischoff, Philippe Goetschel, Daniela Husarik, Ulrich Wili, Luciano Molinari, Christoph Rudin, Alain Gervaix, Urs Hunziker,et al. Randomised trial of oral versus sequential intravenous/oral cephalosporins in children with pyelonephritis