Antibiotic prophylaxis and recurrent urinary tract infection in children pdf
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- NEJM Journal Watch
- Antibiotic Prophylaxis to Prevent Recurrent UTI in Children
- Antibiotic Prophylaxis for Children with Primary Vesicoureteral Reflux: Where Do We Stand Today?
Email: doctormvk gmail. In view of emerging scientific literature, the recommendations have been reviewed. Process: Following a preliminary meeting in November , a document was circulated among the participants to arrive at a consensus on the evaluation and management of these patients.
NEJM Journal Watch
The main goal of the management of vesicoureteral reflux VUR is prevention of recurrent urinary tract infections UTIs , and thereby prevention of renal parenchymal damage possibly ensuing from these infections. Long-term antibiotic prophylaxis is common practice in the management of children with VUR, as recommended in in the guidelines of the American Urological Association. We performed a systematic review to ascertain whether antibiotics can be safely discontinued in children with VUR and whether prophylaxis is effective in the prevention of recurrent UTIs and renal damage in these patients.
Several uncontrolled studies indicate that antibiotic prophylaxis can be discontinued in a subset of patients, that is, school-aged children with low-grade VUR, normal voiding patterns, kidneys without hydronephrosis or scars, and normal anatomy of the urogenital system.
Furthermore, a few recent randomized controlled trials suggest that antibiotic prophylaxis offers no advantage over intermittent antibiotic therapy of UTIs in terms of prevention of recurrent UTIs or new renal damage. Vesicoureteral reflux VUR is defined as the abnormal, retrograde flow of urine from the urinary bladder into the upper urinary tract. VUR can be primary, caused by an anatomically insufficient vesicoureteric junction, or secondary, due to an infravesical obstruction. The retrograde flow of urine from the bladder into the ureter may transport bacteria to the upper urinary tract, possibly predisposing these children to febrile UTI, which can result in permanent renal parenchymal damage.
Ultimately, renal damage results in reflux nephropathy which could cause hypertension and decreased renal function although the risk seems to be lower than previously thought [ 3 — 5 ]. The clinical presentation of patients with VUR is diverse and dependent on age and gender [ 6 ]. Since the widespread use of prenatal ultrasonography, hydronephrosis is often detected in utero, possibly leading to the diagnosis of VUR in the perinatal period [ 8 ].
Neonatal VUR is more common in boys and often associated with congenital renal dysplasia. A history of familial VUR and investigation of an overactive bladder can also lead to the diagnosis of VUR [ 9 , 10 ]. In , the practice guideline from the American Academy of Pediatrics recommended a renal ultrasound and either a classic radiographic voiding cystourethrography or a direct radionuclide cystography after a first UTI in children aged 2—24 months [ 11 ].
However, the recently revised guideline of the National Institute for Health and Clinical Excellence NICE constitutes a major departure from this diagnostic strategy [ 12 , 13 ].
For infants and children without recurrent or atypical UTI, no imaging tests are recommended when they are 6 months or older, and an ultrasound within 6 weeks of the first UTI will suffice when they are younger than 6 months.
The main goal of the management of VUR should be prevention of recurrent febrile UTI, and thereby prevention of the ensuing renal parenchymal damage [ 6 ]. The treatment options include intermittent therapy of episodes of UTI, medical therapy with long-term antibiotic prophylaxis, endoscopic therapy, or surgical therapy.
The desire to update our therapeutic algorithm for children with VUR stimulated us to conduct a systematic review of the role of antibiotic prophylaxis in the management of these children. More specifically, we wanted to ascertain whether antibiotics can be safely discontinued and whether prophylaxis is effective in the prevention of recurrent UTIs and renal damage in these patients. After the search was performed, the titles of all retrieved publications were screened.
If the title indicating the paper was potentially relevant, the abstract was reviewed. The full paper was reviewed if the abstract suggested that the paper was indeed relevant. Five uncontrolled studies evaluated the effect of stopping antibiotic prophylaxis in this patient group [ 15 — 19 ]. Five randomized controlled trials RCTs and one cohort study that compared antibiotic prophylaxis with no treatment i. Two Cochrane systematic reviews and two guidelines on the topic of antibiotic prophylaxis for children with VUR were identified [ 12 , 26 — 28 ].
Instead of performing a meta-analysis on this limited number of RCTs, we present the results of these studies. Long-term antibiotic prophylaxis remains a common practice in the management of children with VUR.
The most commonly used drugs are nitrofurantoin, cotrimoxazole, amoxicillin, and cephalosporins [ 29 , 30 ]. However, these medications may cause side effects and promote the development of resistant bacteria [ 22 , 23 , 25 , 31 ].
Furthermore, the optimal duration of prophylaxis and optimal low dose of antibiotic are unclear, and compliance with this long-term treatment is not always assured. It was then hypothesized that sterilization of the urine could prevent pyelonephritis, and thereby also the resulting parenchymal damage.
Smellie et al. None of the children in the intervention group had a UTI during the prophylaxis period, while 11 children in the control group presented with a UTI. Lohr et al. Each child was placed on nitrofurantoin for 6 months and on placebo for a similar period. There were 35 episodes of bacteriuria 4. Fourteen symptomatic UTIs 1. However, this recommendation was based on expert opinion rather than on clear scientific evidence.
During the following decades, this therapeutic practice has been challenged on multiple occasions. First, several authors demonstrated that in certain circumstances antibiotic prophylaxis can be safely discontinued. Cooper et al. A retrospective chart review revealed 6 episodes None of the children showed new renal scars on renal ultrasound.
However, it should be noted that renal ultrasound has low sensitivity for detection of renal scars. The retrospective chart review by Thompson et al. In addition, the rate of new renal scarring on DMSA scan after stop of antibiotics was comparable with the rate during prophylaxis 2. Hellerstein and Nickell [ 17 ] followed mean follow-up of 3. During the initial course of prophylactic antibiotics, 16 children presented with UTIs, with voiding dysfunction and abnormal kidney s being identified as risk factors for these infections.
Twenty-eight children had UTI during the follow-up period, but 13 of these children were receiving an antibiotic at the time of the infection. Voiding dysfunction was again identified as a risk factor for infection in this time period. Al-Sayyad et al. UTI developed in 9 children None of the children had new renal scarring detected on renal ultrasound. All these children were old enough to describe symptoms of UTI, and had normal voiding patterns, kidneys without hydronephrosis or new scar lesions, and a period of at least 2 years without UTI.
The number of symptomatic UTI episodes was similar during the on- and off-prophylaxis periods: 9 cystitis 3 and pyelonephritis 6 and 8 episodes cystitis 1 and pyelonephritis 7 , respectively. No new scars were detected by DMSA scan at the end of the prophylaxis period 50 children tested and at the end of the follow-up period 33 children tested.
In none of the children, renal function deteriorated. The small studies by Reddy et al. In the study by Reddy et al. In the study by Craig et al. Two children in the placebo group and no child in the antibiotic group developed UTI, and none of the children developed new renal damage on DMSA scan. The multicenter study of Garin et al. Ironically, recurrent acute pyelonephritis was more frequent in the intervention group than in the control group In the updated meta-analysis for the Cochrane Database of Systematic Reviews [ 26 ], the authors stated that the studies by Reddy et al.
Furthermore, they concluded that combined therapy antibiotic prophylaxis plus surgery offers no advantages over antibiotic prophylaxis alone in terms of risk for UTI or renal parenchymal damage.
Conway et al. Age of 3—5 years and high grade of reflux IV or V were identified as risk factors for recurrent UTI; the impact of voiding pattern was not evaluated in this study. They found that antibiotic prophylaxis had no significant effect on the risk of recurrence of UTI hazard ratio of 1. Among the 83 children with recurrent UTI, a nested case-control study was performed to determine risk factors for isolation of resistant bacteria. Antibiotic prophylaxis clearly increased the likelihood of the infection being caused by a resistant pathogen odds ratio of 7.
A French multicenter study by Roussey-Kesler et al. When patients with grades I—III reflux were analyzed separately, again no significant differences were observed , , and , resp. Finally, an Italian multicenter study by Pennesi et al. Thus, the risk for having at least 1 pyelonephritis recurrence was even slightly higher in the intervention group than in the control group relative risk of 1. While all episodes of pyelonephritis in the control group were caused by sensitive strains of Escherichia coli , multiresistant bacteria all resistant to cotrimoxazole among other antibiotics were responsible for all infections in the intervention group.
Furthermore, the presence of renal scars on DMSA scan was the same in children with or without antibiotic prophylaxis relative risk of 1. According to the recently revised NICE guideline, antibiotic prophylaxis is not routinely recommended in children after first-time UTI, and should only be considered after recurrent UTI [ 12 , 13 ].
Despite the lack of evidence for its effectiveness, long-term antibiotic prophylaxis has been a common practice in the management of children with VUR for decades. However, several uncontrolled studies total of children indicate that antibiotic prophylaxis can safely be discontinued in a subset of patients, that is, school-aged children with low-grade VUR, normal voiding patterns, kidneys without hydronephrosis or scars, and normal anatomy of the urogenital system.
More importantly, several recent RCTs suggest that antibiotic prophylaxis with cotrimoxazole offers no advantage over intermittent antibiotic therapy of UTIs in terms of prevention of recurrent UTIs or new renal damage.
However, further research is still warranted in view of the limited number of children total of children studied in these five RCTs. Furthermore, children with high-grade VUR have generally been excluded from these studies, and these findings cannot therefore be generalized.
Finally, one of the RCTs indicates that boys with grade III VUR benefit from antibiotic prophylaxis, and there is a possibility that other subsets of patients, who will benefit from prophylaxis, will be identified in the future. This is an open access article distributed under the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Journal overview. Special Issues. Academic Editor: Hiep Nguyen. Received 30 Apr Revised 02 Jul Accepted 07 Jul Published 29 Jul Abstract The main goal of the management of vesicoureteral reflux VUR is prevention of recurrent urinary tract infections UTIs , and thereby prevention of renal parenchymal damage possibly ensuing from these infections.
Introduction Vesicoureteral reflux VUR is defined as the abnormal, retrograde flow of urine from the urinary bladder into the upper urinary tract. Results and Discussion Long-term antibiotic prophylaxis remains a common practice in the management of children with VUR. Discontinuation of Antibiotic Prophylaxis During the following decades, this therapeutic practice has been challenged on multiple occasions. Conclusion Despite the lack of evidence for its effectiveness, long-term antibiotic prophylaxis has been a common practice in the management of children with VUR for decades.
References M. Faust and H.
Antibiotic Prophylaxis to Prevent Recurrent UTI in Children
Metrics details. An Erratum to this article was published on 27 February Bacterial resistance to antibiotics is an increasingly threatening consequence of antimicrobial exposure for many decades now. We studied the resistance patterns of positive urinary cultures in spina bifida children on clean intermittent catheterization, both continuing and stopping AP. In a cohort of spina bifida patients, 88 continued and 88 stopped using AP. During 18 months, a fortnightly catheterized urine sample for bacterial pathogens was cultured.
Antibiotic Prophylaxis for Children with Primary Vesicoureteral Reflux: Where Do We Stand Today?
Correspondence: Sarah S. E-mail: salsubaie ksu. Recurrent urinary tract infections UTIs in children are associated with development of pyelonephritis and renal scarring.