Treatment of acute pyelonephritis in children
http://www.100md.com
《英国医生杂志》
EDITOR—Lozano's letter is a useful reminder about equivalence and no difference detected. Although I agree that this point should be considered whenever research data are interpreted, the weight given to the width of the confidence intervals is context specific. We believe that our conclusions are reasonable for intravenous or oral antibiotics in children with acute pyelonephritis.
Firstly, the point estimates for all outcomes favour oral and intravenous treatment equally. A benefit of intravenous treatment was not shown in any outcome.
Secondly, the net harms (intravenous cannulation, family separation, risk of nosocomial infection, admission with separation) and costs of intravenous compared with oral, home based, antibiotics are clear. The unproved benefits of intravenous treatment need to be traded against these certain harms.
Thirdly, Lozano suggests that a defect on dimercaptosuccinic acid (DMSA) scanning at six months is clinically important. I disagree. DMSA defects are surrogate end points with uncertain clinical importance, and they continue to resolve for years after development.1 The mismatch between the frequency of DMSA scan abnormalities after urinary tract infections (40% of infections) and clinically important renal disease (hypertension and end stage renal disease, about 1 in 10 000 urinary tract infections) is considerable,2 and in 10% of cases scans are reported as normal by one observer and abnormal by another.3
Waiting for a well conducted equivalence trial with these clinically important outcomes related to DMSA defects is an option, but we estimate a trial of several hundred thousand children with urinary tract infection would be required. In the meantime, oral antibiotics as first line treatment for most post-neonatal infants and children with febrile urinary tract infection remains our preferred option.
Jonathan C Craig, associate professor (clinical epidemiology)
University of Sydney, Children's Hospital at Westmead, NSW 2006, Australia jonc@health.usyd.edu.au
Competing interests: None declared.
References
Stokland E, Hellstrom M, Jacobsson B, Jodal U, Sixt R. Evaluation of DMSA scintigraphy and urography in assessing both acute and permanent renal damage in children. Acta Radiologica 1998;39: 447-52.
Craig JC, Irwig LM, Knight JF, Roy LP. Does treatment of vesicoureteric reflux in childhood prevent end-stage renal disease attributable to reflux nephropathy? Pediatrics 2000;105: 1236-41.
Craig JC, Irwig L, Ford M, Willis NS, Howman-Giles RB, Uren RF, et al. Reliability of DMSA for the diagnosis of renal parenchymal abnormality in children. Eur J Nuclear Med 2000;27: 1610-6.
Firstly, the point estimates for all outcomes favour oral and intravenous treatment equally. A benefit of intravenous treatment was not shown in any outcome.
Secondly, the net harms (intravenous cannulation, family separation, risk of nosocomial infection, admission with separation) and costs of intravenous compared with oral, home based, antibiotics are clear. The unproved benefits of intravenous treatment need to be traded against these certain harms.
Thirdly, Lozano suggests that a defect on dimercaptosuccinic acid (DMSA) scanning at six months is clinically important. I disagree. DMSA defects are surrogate end points with uncertain clinical importance, and they continue to resolve for years after development.1 The mismatch between the frequency of DMSA scan abnormalities after urinary tract infections (40% of infections) and clinically important renal disease (hypertension and end stage renal disease, about 1 in 10 000 urinary tract infections) is considerable,2 and in 10% of cases scans are reported as normal by one observer and abnormal by another.3
Waiting for a well conducted equivalence trial with these clinically important outcomes related to DMSA defects is an option, but we estimate a trial of several hundred thousand children with urinary tract infection would be required. In the meantime, oral antibiotics as first line treatment for most post-neonatal infants and children with febrile urinary tract infection remains our preferred option.
Jonathan C Craig, associate professor (clinical epidemiology)
University of Sydney, Children's Hospital at Westmead, NSW 2006, Australia jonc@health.usyd.edu.au
Competing interests: None declared.
References
Stokland E, Hellstrom M, Jacobsson B, Jodal U, Sixt R. Evaluation of DMSA scintigraphy and urography in assessing both acute and permanent renal damage in children. Acta Radiologica 1998;39: 447-52.
Craig JC, Irwig LM, Knight JF, Roy LP. Does treatment of vesicoureteric reflux in childhood prevent end-stage renal disease attributable to reflux nephropathy? Pediatrics 2000;105: 1236-41.
Craig JC, Irwig L, Ford M, Willis NS, Howman-Giles RB, Uren RF, et al. Reliability of DMSA for the diagnosis of renal parenchymal abnormality in children. Eur J Nuclear Med 2000;27: 1610-6.