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Letters to the Editor

Indian Pediatrics 2002; 39:793-795


We appreciate the comments of Dr. Sanklecha and the opportunity to respond to his concerns. His observations on the dosing frequency for aminoglycosides and the use of cefadroxil are valid for most infectious illnesses, rather than being specific for urinary tract infections.

The suggestion that the total dose of aminoglycoside antibiotics be administered once daily rather than in 2-3 divided doses is valid. Administration of aminoglycosides in a single daily dose has been shown, in multiple studies, to be as effective as divided doses (1-3). No differences were found in microbiological and clinical response in patients given aminoglycosides in single versus divided doses. We, however, reject their comment that ...adverse effects are clearly lower with once a day aminoglycosides. Meta-analyses comparing single versus multiple dose regimens do not show significant differences in the risks of nephrotoxicity, ototoxicity and vestibular toxicity(1,2). Once daily dosing of aminoglycosides is considered effective and safe for most systemic infections including those of the urinary tract. Given the additional convenience and reduced cost of administration, such dosing regimens should be encouraged.

Amoxicillin, cephalexin and cefadroxil are effective against most organisms responsible for urinary tract infections in children and are recommended for oral treatment of such infections. Cefadroxil is a semi-synthetic first generation oral cephalosporin with advantages of almost 100% excretion in the urine within six hours and low cost. The cost of cefadroxil administration, in the developed countries, is almost similar to that of cephalexin and is not prohibitively expensive. Cotrimoxazole is also effective in the treatment of most uncomplicated urinary tract infections, although in vitro resistance is often documented. Any of these antibiotics may be administered as the initial medication in patients with suspected urinary infections. The antibiotic choice might need modification once the report of urine culture and sensitivity is available.

The aim of conservative management of vesicoureteric reflux by antimicrobial prophylaxis is to prevent the occurrence of febrile urinary tract infections and thereby renal scarring. However, the effects of this strategy are difficult to evaluate, since studies in children on antibiotic prophylaxis compared to controls (no prophylaxis, careful supervision, prompt diagnosis and treatment of urinary infections) are lacking. Medications used for prophylaxis of urinary tract infections should have: (i) a satisfactory efficacy against pathogenic organisms, (ii) minimum impact on the normal gut flora, (iii) low risk of developing bacterial resistance, and (iv) few side effects(4). Nitrofurantoin and trimethoprim, which satisfy the above requirements are most often used for long-term, antibacterial prophylaxis(5). Long-term use of other antibiotics, e.g., ampicillin, co-amoxiclav, fluoroquinolones, cefadroxil and cefixime, which alter the indigenous periurethral and bowel flora and promote colonization by pathogenic organisms is not recommended.

Prophylaxis is begun with either cotrimoxazole or nitrofurantoin irrespective of the initial culture results. Cephalexin may be used for short-term in young infants. The patients should be clinically monitored for the occurrence of breakthrough urinary tract infections. Urine cultures are obtained in patients having symptoms of urinary infection. Screening urine cultures are not necessary.

Breakthrough infections should be treated with appropriate antibiotics. In most instances, there is no need to change the medication being used for prophylaxis subsequently. Recurrent breakthrough infections usually result from non-compliance and rarely from development of bacterial resistance, the latter mainly arising with cotrimoxazole. Nitrofurantoin is probably more effective than cotrimoxazole but associated with more gastrointestinal side effects. Patients having repeated breakthrough infections might benefit from double prophylaxis with cotrimoxazole and nitrofurantoin(6). Such patients, as is emphasized in the Consensus Statement(6) should also be assessed for bladder dysfunction.

Arvind Bagga,

P. Hari,

for Indian Pediatric Nephrology Group,

Department of Pediatrics,

All India Institute of Medical Sciences,

Ansari Nagar,

New Delhi 110 029, India.

E-mail: arvindbagga@hotmail.com



1. Ali MZ, Goetz MB. A meta-analysis of the relative efficacy and toxicity of single daily dosing versus multiple daily dosing of aminoglycosides. Clin Infect Dis 1997; 24: 796-809.

2. Galloe AM, Graudal N, Christensen HR, Kampmann JP. Aminoglycosides: single or multiple daily dosing? A meta-analysis on efficacy and safety. Eur J Clin Pharmacol 1995; 48: 39-43.

3. Barza M, Ioannidis JP, Cappelleri JC, Lau J. Single or multiple daily doses of aminoglycosides: a meta-analysis. BMJ 1996; 312: 338-345.

4. Bollgren I. Antibacterial prophylaxis in children with urinary tract infection. Acta Paediatr (Supl) 1999; 88: 48-52.

5. Williams GJ, Lee A, Craig JC. Long-term antibiotics for preventing recurrent urinary tract infection in children (Cochrane Review). Cochrane Database Syst Rev 2001; 4: CD001534.

6. Indian Pediatric Nephrology Group, Indian Academy of Pediatrics. Consensus statement on management of urinary tract infections. Indian Pediatr 2001; 38: 1106-1115.



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