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Continuous antibiotic prophylaxis in the setting of prenatal hydronephrosis and vesicoureteral reflux
Nathan C Wong1, Martin A Koyle2, Luis H Braga1
1Department of Surgery, Division of Urology, McMaster University, Hamilton, ON, Canada.
Insights
Continuous antibiotic prophylaxis (CAP) may benefit children with high-grade prenatal hydronephrosis (HN) and vesicoureteral reflux (VUR), reducing urinary tract infections (UTIs). However, evidence is conflicting, suggesting an individualized approach is best.
Area of Science:
- Pediatric Nephrology
- Infectious Diseases
- Urology
Background:
- Continuous antibiotic prophylaxis (CAP) is traditionally used for children with recurrent urinary tract infections (UTIs) or at-risk conditions like prenatal hydronephrosis (HN) and vesicoureteral reflux (VUR).
- Current guidelines offer inconclusive recommendations due to controversial indications and conflicting data regarding the benefits of CAP.
- Evidence for CAP in prenatal HN primarily comes from observational studies, while VUR has been investigated in multiple randomized trials.
Purpose of the Study:
- To evaluate the efficacy of continuous antibiotic prophylaxis in preventing UTIs in children with specific urological conditions.
- To synthesize existing evidence regarding CAP for children with prenatal hydronephrosis and vesicoureteral reflux.
- To inform clinical decision-making and guideline development for antibiotic prophylaxis in pediatric urology.
Main Methods:
- Systematic review of observational studies for high-grade prenatal hydronephrosis.
- Meta-analysis of eight randomized trials investigating CAP for vesicoureteral reflux.
- Analysis of study heterogeneity and inclusion criteria to explain conflicting results.
Main Results:
- For high-grade prenatal HN, CAP showed a benefit with an estimated number needed to treat of 7 for preventing infections; no benefit was observed for low-grade HN.
- Meta-analysis of VUR studies indicated an overall benefit of CAP in preventing infections, despite four trials showing no value.
- Significant heterogeneity across studies likely contributes to the conflicting findings.
Conclusions:
- CAP may be beneficial for select pediatric patients with high-grade HN and VUR, but evidence quality varies.
- An individualized approach is recommended, considering patient-specific factors and comparing them to populations in existing studies.
- Further high-quality randomized trials are needed to clarify definitive indications for CAP in these pediatric populations.
Abstract:
Continuous antibiotic prophylaxis (CAP) has traditionally been offered for children with recurrent urinary tract infections (UTIs) or those at risk, including children diagnosed with prenatal hydronephrosis (HN) and vesicoureteral reflux (VUR). However, indications for antibiotic prophylaxis are controversial, data on who should benefit from this therapy is conflicting and, thus, guidelines are unable to provide conclusive recommendations. In the setting of prenatal HN, although randomized trials are currently underway, most evidence is derived from low- to moderate-quality observational studies. Although there is no benefit in those with low-grade HN, a systematic review of the available studies showed that high-grade HN patients on prophylaxis experienced fewer infections with an estimated number needed to treat of 7. On the other hand, there are eight randomized trials that have investigated the use of antibiotic prophylaxis in the setting of VUR. Although four of the studies have demonstrated some value of prophylaxis and the other four have not, meta-analysis has shown an overall benefit of antibiotic prophylaxis in preventing infections. The observed differences are likely due to different inclusion criteria and study heterogeneity. Although generalizing results of meta-analyses to all children is tempting, an individualized approach, by determining which patients best behave like those of the included studies, is recommended.
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