Background
Urinary tract infection (UTI) is one of the most common bacterial infections in childhood and is associated with long-term complications. We aimed to assess the effect of adjuvant ...dexamethasone treatment on reducing kidney scarring after acute pyelonephritis (APN) in children.
Methods
Multicenter, prospective, double-blind, placebo-controlled, randomized clinical trial (RCT) where children from 1 month to 14 years of age with proven APN were randomly assigned to receive a 3-day course of either an intravenous corticosteroid (dexamethasone 0.30 mg per kg/day) twice daily or placebo. The late technetium 99 m-dimercaptosuric acid scintigraphy (> 6 months after acute episode) was performed to assess kidney scar persistence. Kidney scarring risk factors (vesicoureteral reflux, kidney congenital anomalies, or urinary tract dilatation) were also assessed.
Results
Ninety-one participants completed the follow-up and were finally included (dexamethasone
n
= 49 and placebo
n
= 42). Both groups had similar baseline characteristics. Twenty participants showed persistent kidney scarring after > 6 months of follow-up without differences in incidence between groups (22% and 21% in the dexamethasone and placebo groups,
p
= 0.907). Renal damage severity in the early DMSA (β = 0.648,
p
= 0.023) and procalcitonin values (β = 0.065
p
= 0.027) significantly modulated scar development. Vesicoureteral reflux grade showed a trend towards significance (β = 0.545,
p
= 0.054), but dexamethasone treatment showed no effect.
Conclusion
Dexamethasone showed no effect on reducing the risk of scar formation in children with APN. Hence, there is no evidence for an adjuvant corticosteroid treatment recommendation in children with APN. However, the study was limited by not achieving the predicted sample size and the expected scar formation.
Trial registration
Clinicaltrials.gov, NCT02034851. Registered in January 14, 2014.
Graphical abstract
“A higher resolution version of the Graphical abstract is available as Supplementary information.”
Aim
Febrile urinary tract infection is a common bacterial infection in childhood. The kidney damage after acute pyelonephritis (APN) could be related to the stimulation of the proinflammatory ...response. We aimed to investigate the role of inflammatory cytokines and the effect of dexamethasone after a first episode of APN.
Methods
Subanalysis of the DEXCAR RCT in which children with confirmed APN (1 month–14 years) were randomly assigned to receive a 3 days course of either intravenous dexamethasone or placebo. Urinary cytokine levels at diagnosis and after 72 h of treatment were measured.
Results
Ninety‐two patients were recruited. Younger patients, males and those with abnormalities in the ultrasound study or vesicoureteral reflux showed higher values of urinary cytokines. Patients with severe APN had higher Tumour Necrosis Factor (TNF)α levels (81.0 ± 75.8 vs. 33.6 ± 48.5 pg/mg creatinine, p = 0.015). Both intervention groups showed similar basal clinical characteristics, including urinary cytokine levels. Treatment reduced urinary cytokine levels irrespective of dexamethasone administration. Neither the intervention group nor the urinary cytokine levels modulated the development of kidney scars.
Conclusion
Basal urinary cytokines were associated with age, abnormal ultrasound and vesicoureteral reflux. Patients with severe APN had higher TNFa urinary levels. Administration of dexamethasone in children with APN does not improve the control of the proinflammatory cytokine cascade.
: Case report.
: To describe a case of septic arthritis of the facet joint in an infant.
: To our knowledge, no more than 50 cases of septic arthritis of a facet joint are reported in literature, ...including only 4 cases in children and none in infants.
: A girl of age 18 months presented with a fever pattern of 4 days evolution, right lumbar paravertebral tumefaction with local inflammatory signs and limping related to pain with weight-bearing on the right lower extremity. The mother reported a pharyngeal infection 2 weeks earlier.Conventional radiology showed no alterations. MR and scintigraphy with radioactivity-marked leukocytes showed affectation only of the posterior facet joint of right L4-L5, without associated collections. Blood and urine cultures were negative. The diagnosis was established as right L4-L5 septic arthritis of a lumbar facet joint, probably of hematogenous origin.
: The fever pattern and the limp disappeared in 24 hours with wide-spectrum empirical intravenous antibiotherapy. Although no microorganism was isolated, the good response to the empirical treatment and the background of pharyngeal infection point to a hematogenous dissemination by Staphylococcus aureus or Streptococcus spp.
: Septic arthritis of a facet joint does not differ clinically from other spinal infections and its incidence is possibly underestimated in favor of other more common entities. Only imaging techniques can differentiate the affected structures and establish the exact diagnosis.MR allows the detection in initial stages, delimits the affectation and extension through the soft tissues, and rules out other more common entities such as discitis. Scintigraphy and SPECT can detect other active foci and be useful in the follow-up.The result achieved with antibiotic treatment in early stages is usually satisfactory. Surgical debridement is only necessary when associated purulent collections appear. From the pediatric point of view, spinal infections should also be taken into consideration within the differential diagnostic of limp in children.
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