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M Shahid, Department of Paediatrics, Portiuncula Hospital, Ballinasloe, County Galway, Ireland; email@example.com
R Cooke, Department of Paediatrics, Portiuncula Hospital, Ballinasloe, County Galway, Ireland
An 8‐month‐old infant is admitted with fever and vomiting. Urinary tract infection (UTI) is diagnosed. You decide to commence IV treatment with gentamicin. In your paediatric ward, gentamicin is routinely administered in three times daily dose (TD) regimens but you look up gentamicin administration in the BNF for children and find that it can be given once daily (OD). This prompts debate amongst staff as to whether the same can be done on your ward. Everyone wonders whether there is any supportive evidence for efficacy and safety when OD gentamicin is used in the treatment of UTI.
In children aged 1 month to 18 years with UTI [patients], is OD gentamicin [intervention] as compared with TD gentamicin [comparator] as effective in resolving UTI and as safe [outcome]?
Cochrane database, DARE, ACP Journal Club and EBM were explored. We could not find any systematic reviews explicitly answering our question.
Medline (Ovid Medline) 1966–February 2007
“Urinary Tract Infection” and “Gentamicin or gentam$”
Limits: human, English language, all child (0 to 18 years), clinical trial
No appropriate primary studies could be found from Cochrane Central, Cinahl or Embase.
32 citations; three were relevant. See table 33.
UTIs are the second most common infection in children, after those of the ear and throat.1 If intravenous antibiotics are required, aminoglycosides or third generation cephalosporins are usually used. Escherichia coli is a causative organism in 80–90% of cases2 of UTI in children, making it a suitable clinical setting for aminoglycoside use in children. When compared to cephalosporins, aminoglycosides are favoured because of their efficacy, low rate of resistance,3 widespread availability and low cost. Gentamicin is frequently used to treat UTI in children because of experience with its use and its relatively low cost.4 In addition, because other aminoglycosides, such as tobramycin, may be more useful in other clinical settings, gentamicin is used in UTI to minimise use of such drugs and, the development of drug resistance. Many clinical trials in adults and neonates5–9 have proven that OD gentamicin can be used with equal or better efficacy and similar or decreased ototoxicity and nephrotoxicity as compared with conventional TD dosing. A meta‐analysis recently assessed the safety and efficacy of OD dosing of aminoglycosides as compared with multiple dosing in children.10 This meta‐analysis included 24 studies where different aminoglycosides were used in different clinical settings. The authors concluded that although single trials have been small, the available randomised evidence supports the general adoption of OD dosing of aminoglycosides in paediatric clinical practice.
Specifically, the use of OD versus TD dosing of gentamicin in children with UTI is addressed by the three studies11–13 selected, The evidence extracted from these studies supports the use of OD gentamicin in the treatment of UTI in children, but certain gaps have been identified. These include the variation in gentamicin dose (OD varied from 4.5 to 7.5 mg/kg/day) and the estimation of ototoxicity and nephrotoxicity. Since it is thought that the prevalence of ototoxicity due to aminoglycoside is low in paediatric patients, large patient samples are needed with near complete follow‐up of participants. These aspects were weak in these three studies. In the study conducted by Carapetis et al,12 base‐line and follow‐up audiology examinations were obtained in 28 (31%) and 39 (43%) patients in the OD group and 16 (18%) and 33 (37%) in the TD group. Tapaneya‐Olarn et al13 did not measure ototoxicity in their outcome. As regards nephrotoxicity, there is lack of consensus regarding the best way to assess renal damage Carapetis et al referred to a method of assessing renal damage through the presence of tubular enzymes in urine but did not use this method in their study.