Antibiotic Prophylaxis for Vesicoureteral Reflux

Posted by • June 6th, 2014

Are Charlie’s kidneys backed up?  Does he need antibiotics?  His parents want to know if 2-year-old Charlie is going to be on long-term antibiotics to prevent any new bladder infections.  He’s just finished treatment for a urinary tract infection (UTI).    You explain that a voiding cystourethrogram will need to be done first to categorize the grade of reflux and then you’ll talk.  Original research published recently in NEJM describes the uncertainty of the value of antibiotic prophylaxis in altering vesicoureteral reflux (VUR).

Randomized clinical trials are the currency by which medical treatments are evaluated, but the trials don’t always produce definitive results.  That’s the case with the Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) trial.

About a third of febrile children with UTIs may experience VUR, which can lead to renal scarring.   Some individuals with VUR are at an increased risk for pyelonephritis, hypertension, and progressive renal failure. However, the severity of VUR greatly varies and thus may affect patients differently.

The trial, which enrolled 607 children at 19 sites, was designed to evaluate the effectiveness of long-term antimicrobial prophylaxis in preventing febrile or symptomatic recurrence of UTIs.  Secondary outcomes evaluated the likelihood of renal scarring and treatment failure and antimicrobial resistance.  Enrolled children received either trimethoprim sulfamethoxazole or placebo and were tracked for two years.

Fewer recurrent UTIs were documented in the prophylaxis group than in the placebo group (RR 0.55, 95% CI 0.38-0.78).  However, antibiotic resistance was more common in the group getting antibiotic prophylaxis than in the placebo group (63% vs. 19%). No significant difference in renal scarring was noted between the two groups at the 2-year observation.

In an accompanying editorial, NEJM Deputy Editor Dr. Julie Ingelfinger and Dr. Bruder Stapleton noted that the decision to use antibiotic prophylaxis “remains a clinical dilemma” because the RIVUR study demonstrated that antibiotic resistance occurred more often in the arm assigned to prophylaxis and because no difference in renal scarring was found between the two groups.  The editorialists wrote that the RIVUR study results suggest that a general recommendation of antibiotic prophylaxis for children with VUR needs more evidence before it can universally adopted.

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