Can prophylactic antibiotics safely be discontinued in children with vesicoureteral reflux?

We review the outcome of stopping prophylactic antibiotics in children with persistent vesicoureteral reflux (VUR).

We performed a retrospective chart review of patients with VUR followed off antibiotics during the last 12 years. Selection criteria included children 4 years old or older who were toilet trained, could verbalize and had a normal voiding pattern. Exclusion criteria were posterior urethral valves, ectopic ureter, neurogenic bladder and severe voiding dysfunction. Outcome measures were age at stopping antibiotics, duration on and off antibiotics, grade of reflux at the time of stopping antibiotics, the occurrence of urinary tract infections (UTI) and new renal scarring on followup. All patients had upper tract assessment performed with renal ultrasound.

A total of 67 girls (85.9%) and 11 boys (14.1%) were included in the analysis. VUR was bilateral in 36 patients (46.2%), on the left side in 29 (37.2%) and on the right side in 13 (16.7%). Reflux was grade I in 16.7% of the cases, II in 75.6% and III in 7.7%. Mean patient age when taken off antibiotics was 5.74 years. The period on prophylactic antibiotics ranged from 0 to 84 months (mean 26.2) and the period off antibiotics ranged from 5 to 138 months (37.7). UTI developed in 9 girls (11.5%), of whom 8 had cystitis (10.2%) and 1 had clinically presumptive pyelonephritis (1.3%). These 9 girls were off antibiotics 5 to 60 months (mean 21.1). None of our patients, including those with UTI, had new renal scarring on followup renal ultrasound.

Discontinuing prophylactic antibiotics in selected school age children is safe practice. The risk of significant upper tract infection is low and the development of new renal scars unlikely. However, we fully acknowledge that renal ultrasound is not the most accurate investigation for detection of renal scars. Therefore, continuing medical surveillance of these children is important.