Could prophylactic antibiotics be stopped in patients with history of vesicoureteral reflux?

Evidence-based clinical practice guideline for management of urinary tract infection and primary vesicoureteric reflux

We present updated, evidence-based clinical practice guidelines from the Indian Society of Pediatric Nephrology (ISPN) for the management of urinary tract infection (UTI) and primary vesicoureteric reflux (VUR) in children. These guidelines conform to international standards; Institute of Medicine and AGREE checklists were used to ensure transparency, rigor, and thoroughness in the guideline development. In view of the robust methodology, these guidelines are applicable globally for the management of UTI and VUR. Seventeen recommendations and 18 clinical practice points have been formulated. Some of the key recommendations and practice points are as follows. Urine culture with > 104 colony forming units/mL is considered significant for the diagnosis of UTI in an infant if the clinical suspicion is strong. Urine leukocyte esterase and nitrite can be used as an alternative screening test to urine microscopy in a child with suspected UTI. Acute pyelonephritis can be treated with oral antibiotics in a non-toxic infant for 7-10 days. An acute-phase DMSA scan is not recommended in the evaluation of UTI. Micturating cystourethrography (MCU) is indicated in children with recurrent UTI, abnormal kidney ultrasound, and in patients below 2 years of age with non-E. coli UTI. Dimercaptosuccinic acid scan (DMSA scan) is indicated only in children with recurrent UTI and high-grade (3-5) VUR. Antibiotic prophylaxis is not indicated in children with a normal urinary tract after UTI. Prophylaxis is recommended to prevent UTI in children with bladder bowel dysfunction (BBD) and those with high-grade VUR. In children with VUR, prophylaxis should be stopped if the child is toilet trained, free of BBD, and has not had a UTI in the last 1 year. Surgical intervention in high-grade VUR can be considered for parental preference over antibiotic prophylaxis or in children developing recurrent breakthrough febrile UTIs on antibiotic prophylaxis.

Guidelines for the medical management of pediatric vesicoureteral reflux

Urinary tract infection is a bacterial infection that commonly occurs in children. Vesicoureteral reflux is a major underlying precursor condition of urinary tract infection, and an important disorder in the field of pediatric urology. Vesicoureteral reflux is sometimes diagnosed postnatally in infants with fetal hydronephrosis diagnosed antenatally. Opinions vary regarding the diagnosis and treatment of vesicoureteral reflux, and diagnostic procedures remain debatable. In terms of medical interventions, options include either follow‐up observation in the hope of possible spontaneous resolution of vesicoureteral reflux with growth/development or provision of continuous antibiotic prophylaxis based on patient characteristics (age, presence/absence of febrile urinary tract infection, lower urinary tract dysfunction and constipation). Furthermore, there are various surgical procedures with different indications and rationales. These guidelines, formulated and issued by the Japanese Society of Pediatric Urology to assist medical management of pediatric vesicoureteral reflux, cover the following: epidemiology, clinical practice algorithm for vesicoureteral reflux, syndromes (dysuria with vesicoureteral reflux, and bladder and rectal dysfunction with vesicoureteral reflux), diagnosis, treatment (medical and surgical), secondary vesicoureteral reflux, long‐term prognosis and reflux nephropathy. They also provide the definition of bladder and bowel dysfunction, previously unavailable despite their close association with vesicoureteral reflux, and show the usefulness of diagnostic tests, continuous antibiotic prophylaxis and surgical intervention using site markings.

Antibiotic prophylaxis and reflux: critical review and assessment

The use of continuous antibiotic prophylaxis (CAP) was critical in the evolution of vesicoureteral reflux (VUR) from a condition in which surgery was the standard of treatment to its becoming a medically managed condition. The efficacy of antibiotic prophylaxis in the management of VUR has been challenged in recent years, and significant confusion exists as to its clinical value. This review summarizes the critical factors in the history, use, and investigation of antibiotic prophylaxis in VUR. This review provides suggestions for assessing the potential clinical utility of prophylaxis.

Early discontinuation of antibiotic prophylaxis in patients with persistent primary vesicoureteral reflux initially detected during infancy: outcome analysis and risk factors for febrile urinary tract infection

PURPOSE

We retrospectively assessed the incidence of and risk factors for febrile urinary tract infection in children during active surveillance after early discontinuation of antibiotic prophylaxis.

MATERIALS AND METHODS

We retrospectively evaluated 9 females and 61 uncircumcised males diagnosed with primary vesicoureteral reflux before age 1 year who had persistent reflux on followup voiding cystourethrogram and were subsequently followed under active surveillance without continuous antibiotic prophylaxis. Patients with secondary vesicoureteral reflux or associated urological abnormality were excluded. Clinical outcomes, including incidence of febrile urinary tract infection and new scar formation, were evaluated. Risk factors for febrile urinary tract infection were also analyzed.

RESULTS

Mean age at stopping continuous antibiotic prophylaxis was 21 months, and mean followup was 61 months. During active surveillance 21 patients had febrile urinary tract infection, and the 5-year infection-free rate under active surveillance was 67.5%. One or 2 foci of minimal new scarring developed in 4 of 16 patients who underwent followup dimercapto-succinic acid scan after febrile urinary tract infection. On multivariate analysis dilated vesicoureteral reflux on followup voiding cystourethrogram was the only significant risk factor for febrile urinary tract infection.

CONCLUSIONS

This study revealed that about two-thirds of patients with persistent vesicoureteral reflux were free of febrile urinary tract infection during 5 years of active surveillance. Those with dilated vesicoureteral reflux on followup voiding cystourethrogram are at significantly greater risk for febrile urinary tract infection. Accordingly active surveillance, especially in patients with nondilated vesicoureteral reflux on followup voiding cystourethrogram, seems to be a safe option even in children who have not yet been toilet trained.

[Primary vesicoureteral reflux]

The never ending discussion about the diagnostics and treatment of vesicoureteral reflux (VUR) now includes arguments for diagnostic nihilism as well as invasive diagnostics and therapy, which is reminiscent of the debate on prostate cancer in adulthood. The common goal of all currently competing diagnostic strategies and approaches is the prevention of renal scars by the most effective and least burdensome approach. There is a difference between acquired pyelonephritic scars with VUR (acquired reflux nephropathy) and congenital reflux nephropathy (primary dysplasia) which cannot be influenced by any therapy.The VUR can be verified by conventional radiological voiding cystourethrography (VCUG), by urosonography, radionuclide cystography or even by magnetic resonance imaging (MRI). The guidelines of the European Association of Urology/European Society for Paediatric Urology (EAU/ESPU) recommend radiological screening for VUR after the first febrile urinary tract infection. Significant risk factors in patients with VUR are recurrent urinary tract infections (UTI) and parenchymal scarring and the patients should undergo patient and risk-adapted therapy. Infants with dilating reflux have a higher risk of renal scarring than those without dilatation of the renal pelvis. Bladder dysfunction or dysfunctional elimination syndrome represents a well-known but previously neglected risk factor in combination with VUR and should be treated prior to any surgical intervention as far as is possible.Certainly not every patient with VUR needs therapy. The current treatment strategies take into account age and gender, the presence of dysplastic or pyelonephritic renal scars, the clinical symptoms, bladder dysfunction and frequency and severity of recurrent UTI as criteria for the therapy decision. The use of an antibacterial prophylaxis as well as the duration is controversially discussed. Endoscopic therapy can be a good alternative to antibacterial prophylaxis or a surveillance strategy in patients with low grade VUR. In patients with dilating VUR and given indications for surgery, endoscopic treatment can be offered. However, parents should be completely informed about the significantly lower success rate of endoscopic therapy compared to open surgical procedures. The open surgical techniques guarantee the highest success rates and should be used in patients with a dilating VUR and high risk of renal damage.

Current options in the management of primary vesicoureteral reflux in children

The management of vesicoureteral reflux (VUR) is varied and remains controversial, which is likely because children with VUR have different risks for urinary tract infection or renal injury. Consequently, the treatment of VUR needs to be individualized based on the patient's characteristics. In this article, the authors review the medical and surgical management options for VUR in the pediatric population. The authors hope to provide a systematic approach to determine which treatment is optimal for a specific patient.

Outcome of antibiotic prophylaxis discontinuation in patients with persistent vesicoureteral reflux initially presenting with febrile urinary tract infection: time to event analysis

PURPOSE

The use of antibiotic prophylaxis for preventing urinary tract infections has recently been called into question. Some studies support discontinuation of antibiotic prophylaxis in selected groups of children with vesicoureteral reflux. We report on the outcome of this practice in a cohort of patients assembled based on initial presentation with a febrile urinary tract infection.

MATERIALS AND METHODS

We retrospectively reviewed records of patients with persistent vesicoureteral reflux without symptoms suggestive of dysfunctional elimination who discontinued antibiotic prophylaxis after being toilet trained. Exclusion criteria consisted of secondary reflux and previous surgery for vesicoureteral reflux. End points included development of febrile urinary tract infections, renal abnormalities on followup ultrasound and need for further interventions. Infection-free survival was analyzed using the Kaplan-Meier method and compared using the log rank and Cox's tests.

RESULTS

We evaluated 84 girls and 26 boys with a mean age of 5.4 years. Febrile urinary tract infections developed in 10 girls and 1 boy at an average of 17.2 months after discontinuation of antibiotic prophylaxis. In a time to event analysis group comparison showed no significant differences when patients were stratified by gender (p = 0.22), age at antibiotic prophylaxis discontinuation (p = 0.14) or disease laterality (p = 0.23). However, a significant difference was found in number of patients with high grade vesicoureteral reflux (III to V, p = 0.05) and development of symptoms suggestive of bladder/bowel dysfunction (p <0.01).

CONCLUSIONS

Our data support antibiotic prophylaxis discontinuation in the majority of patients with persistent vesicoureteral reflux who initially present with a febrile urinary tract infection, once their elimination habits have been optimized. Those with high grade reflux appear to be at increased risk for recurrent urinary tract infections. Development of dysfunctional elimination symptoms appears to be a risk factor amenable to treatment.

Is antibiotic prophylaxis effective in preventing urinary tract infections in patients with vesicoureteral reflux?

The main concern in the management of children with vesicoureteral reflux (VUR) is the prevention of urinary tract infections and avoidance of renal damage. Medical management has been recommended or preferentially suggested over surgery in all but a few select clinical situations. Prophylactic antibiotics are prescribed routinely in the management of young children with radiological evidence of VUR following an episode of acute pyelonephritis. Prophylaxis is generally maintained until the VUR resolves spontaneously or is corrected surgically. Although the administration of prophylactic antibiotics has been universal in children with VUR, some authors have reported that long-term antibiotic prophylaxis does not fully prevent urinary tract infections or scarring, that antibiotic-related adverse events are known to occur, and that the incidence of pyelonephritis does not increase in spite of prophylactic antibiotic cessation. Recently, four prospective, randomized, controlled trials of antibiotic prophylaxis for preventing pyelonephritis and renal scarring were reported and some placebo-controlled, double-blind prospective studies are ongoing. The goal of this review is to evaluate the treatment of VUR using antibiotic prophylaxis, and its advantages and disadvantages based on appropriate descriptions and studies in the literature.