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| EDITORIAL |
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| Year : 2022 | Volume
: 7
| Issue : 1 | Page : 1-2 |
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Is antibiotic prophylaxis mandatory to prevent renal damage or recurrence of UTI?
Md Habibur Rahman
Department of Pediatric Nephrology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| Date of Submission | 20-Feb-2022 |
| Date of Acceptance | 05-Mar-2022 |
| Date of Web Publication | 31-May-2022 |
Correspondence Address:
Prof. Md Habibur Rahman
Department of Pediatric Nephrology, Bangabandhu Sheikh Mujib Medical University, Dhaka 1000
Bangladesh
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/pnjb.pnjb_9_22
How to cite this article:
Rahman MH. Is antibiotic prophylaxis mandatory to prevent renal damage or recurrence of UTI?. Paediatr Nephrol J Bangladesh 2022;7:1-2 |
Children with urinary tract infection (UTI) and urinary tract abnormality like vesicoureteric reflux (VUR) are treated with prophylactic antibiotics to prevent kidney damage. Even this antibiotic prophylaxis (ABP) is practiced with normal urinary tract to mitigate patients suffering due to recurrent symptomatic UTI. These recommendations are mostly individualized, nonrandomized, and were done before advanced modalities are available. It may be mentioned that acute pyelonephritis-related renal scar formation and tubulointerstitial damage depends on host response, tubular injury, and ischemia during the acute phase of pyelonephritis. The range of scar formation may vary from 50% to 85% in children during the first episode of acute pyelonephritis as detected by DMSA scan at acute phase.[1],[2],[3] It has been observed that overall 75% of UTIs may recur in infancy after the first episode and it may happen in 40% of girls and 30% of boys with first UTI after the age of one year.[4],[5] For long time, prophylactic antibiotic therapy is practiced in children with the first episode of UTI with or without urological abnormalities to prevent renal scar and recurrence of UTI. But recently different systematic reviews of six randomized trials on ABP after UTI with normal urinary tract revealed that the rate of infection ranges from 0 to 4 UTI in the treatment group and 0 to 16 UTI for the control group.[6]All the systematic reviews concluded that use of prophylactic antibiotics to prevent UTI with normal anatomy is of low quality rather well designed trials are needed to optimize the use of antimicrobials in children with recurrent UTI. A Cochrane 2006 review compared ABP with placebo/no treatment for 10 weeks to 12 months revealed that antibiotics reduced positive urine culture but found no evidence to prevent recurrent symptomatic UTI.[6] National Institute for Health and Clinical Excellence (NICE) also recommended that ABP should not be routinely used in children following first UTI.[4],[5]
A recent retrospective analysis of 74,974 children below 6 years over a period of 5 years revealed that significant predictors of recurrence of UTI were white race, age 3 to 5 years, higher grades of reflux rather than sex, lower grade reflux, and antimicrobial exposure. Moreover, antimicrobial prophylaxis does not cause a significant delay between initial UTI and first recurrence rather such type of practice increase 7.5 fold risk of a resistant pathogen causing the recurrence of UTI. So they recommended not to use ABP among the children to prevent recurrent UTI and emergence of resistant infections.[7]
Use of prophylactic antibiotics in children with VUR-associated UTI depends on risk stratification rather than the only mere presence of VUR because of prophylaxis reduced morbidity related with UTI and does not reduce the risk of the renal scar. The natural history of primary VUR is to improve or resolution observed by different studies. The Birmingham reflux study confirmed 50% cessation of moderate-to-severe VUR after 5 years.[8] The International Reflux Study in children found that 25% negative VCUG leads to disappearance of 80% nondilated and 40% dilated ureters. After 5 years follow-up of children less than 5 years, rate of resolution of different grades of reflux is like as grade 1 reflux 82%, grade 11 80%, and grade 111 reflux 46%, respectively.[9] On the contrary, Schwab et al.[10] reported 13% resolution of grade 1 to 111 VUR per year for the first year and subsequently 3.5% per year and grade 1V and V resolved at a rate of 5% per year.
Though the natural history of the VUR is to improve or resolution with time, traditional practice is to give long-term ABP until the resolution of VUR by the belief that VUR predisposes to recurrent UTI and renal parenchymal damage. Many professional societies like American Academy of Pediatrics (AAP), American Urological Association (AUA), and Swedish Medical Research Council (SMRC) endorsed recommendation of prophylactic antibiotic in the prevention of renal injury in young children with VUR.[11],[12],[13] Their evidence-based recommendations are based on the severity of VUR, unilateral or bilateral VUR, presence or absence of renal scarring and clinical course of VUR. Opinion differs between AUA and SMRC about prophylaxis in lower grade of VUR, AUA recommends it but SMRC does not recommend it in lower grade of VUR. On the contrary, AAP advocated continuation of ABP until imaging revealed resolution of VUR.[10] The RIVUR trial (NCT00405704) showed that ABP by cotrimoxazole reduced recurrence rate of UTI by 50% and more in girls who had febrile UTI along with BBD and limited those who had grade III–IV VUR without BBD.[14] This study also showed that reduction rate of symptomatic UTI was significantly lower in the treatment group compared with the placebo group (13% vs. 24%; hazard ratio 0.50; 95%CI, 0.34–0.74). Many controversies still persist regarding long-term prophylaxis antibiotic, surgical treatment, or no treatment to prevent renal damage due to UTI and VUR in different systematic analysis, even in another systematic analysis evaluated that VUR is a weak predictor of renal damage in children with febrile UTI.[15],[16] Though controversy also exists regarding timing of follow-up by VCUG to see the VUR resolution, most of the researchers advocated that every 2 years VCUG should be done in the grade 1 and 11 VUR and every 3 years in grades III or higher.
The role of ABP in the management of hydronephrosis (HN), VUR, and ureterocele is still controversial though main some benefit was observed in patients affected by high-grade HN and VUR. But in mild HN and low-grade VUR did not show benefit with the long-term use of continuous antibiotic prophylaxis (CAP).[17]
Till now, none of the systematic analyses strongly have given any strong recommendation regarding the use or not to use of prophylactic antibiotics in children with UTI and VUR to prevent renal scar. The prevention of renal scars following UTI remains the most important factor and VUR and UTI are considered as risk factors of renal scarring. Therefore, prophylactic antibiotics may be practiced without breaking the long-continued traditional norms, until and unless the role of antibiotics is established by a multicenter, prospective, randomized, and placebo-controlled study in children with VUR.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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