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Antibiotics and surgery for vesicoureteric reflux: a meta-analysis of randomised controlled trials
D Wheeler1, D Vimalachandra, E M Hodson
1Centre for Kidney Research and Cochrane Renal Group, NHMRC Centre of Clinical Research Excellence in Renal Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia.
Insights
Treating vesicoureteric reflux (VUR) in children with surgery or antibiotics shows no significant difference in preventing urinary tract infections (UTIs) or renal damage. The added benefit of surgery over antibiotics alone appears minimal.
Area of Science:
- Pediatric Urology
- Nephrology
- Evidence-Based Medicine
Background:
- Vesicoureteric reflux (VUR) is a common condition in children, increasing the risk of urinary tract infections (UTIs) and potential renal damage.
- Current treatment strategies include long-term antibiotic prophylaxis and surgical correction.
Purpose of the Study:
- To systematically evaluate the comparative benefits and harms of different treatments for VUR in pediatric patients.
- To assess the impact of medical and surgical interventions on UTI incidence, renal damage, and kidney function.
Main Methods:
- A meta-analysis of randomized controlled trials (RCTs) was conducted using a random effects model.
- Key outcome measures included the incidence of UTIs, new or progressive renal damage, renal growth, hypertension, and glomerular filtration rate.
Main Results:
- Eight trials involving 859 children were analyzed, comparing antibiotics with surgery, and antibiotics with no treatment.
- No significant difference in UTI risk was observed between surgical and medical management at 2 and 5 years.
- While combined treatment reduced febrile UTIs by 60% at 5 years, it did not significantly reduce the risk of new or progressive renal damage.
Conclusions:
- The clinical benefit of identifying and treating VUR in children remains uncertain.
- The additional benefit of surgical intervention over antibiotic therapy alone is minimal.
- Preventing one febrile UTI with surgery requires approximately nine reimplantations, without reducing overall UTI or renal damage incidence.
Aims:
To evaluate the benefits and harms of treatments for vesicoureteric reflux in children.
Methods:
Meta-analyses of randomised controlled trials using a random effects model. Main outcome measures were incidence of urinary tract infection (UTI), new or progressive renal damage, renal growth, hypertension, and glomerular filtration rate.
Results:
Eight trials involving 859 evaluable children comparing long term antibiotics with surgical correction of reflux (VUR) and antibiotics (seven trials) and antibiotics compared with no treatment (one trial) were identified. Risk of UTI by 1-2 and 5 years was not significantly different between surgical and medical groups (relative risk (RR) by 2 years 1.07; 95% confidence interval (CI) 0.55 to 2.09, RR by 5 years 0.99; 95% CI 0.79 to 1.26). Combined treatment resulted in a 60% reduction in febrile UTI by 5 years (RR 0.43; 95% CI 0.27 to 0.70) but no concomitant significant reduction in risk of new or progressive renal damage at 5 years (RR 1.05; 95% CI 0.85 to 1.29). In one small study no significant differences in risk for UTI or renal damage were found between antibiotic prophylaxis and no treatment.
Conclusion:
It is uncertain whether the identification and treatment of children with VUR confers clinically important benefit. The additional benefit of surgery over antibiotics alone is small at best. Assuming a UTI rate of 20% for children with VUR on antibiotics for five years, nine reimplantations would be required to prevent one febrile UTI, with no reduction in the number of children developing any UTI or renal damage.