Continuous antibiotic prophylaxis in isolated prenatal hydronephrosis
Joshua D Chamberlin1, Luis H Braga2, Carol A Davis-Dao3
1Loma Linda University, Department of Pediatric Urology, Loma Linda, CA, USA; CHOC Children's, Division of Pediatric Urology, Orange, CA, USA.
Insights
Continuous antibiotic prophylaxis (CAP) did not significantly reduce urinary tract infection (UTI) rates in children with isolated prenatal hydronephrosis (PNH). Clinicians should assess individual risk factors before prescribing CAP for PNH patients.
Area of Science:
- Pediatric Urology
- Congenital Anomalies
- Infectious Disease Prevention
Background:
- Prenatal hydronephrosis (PNH) is a common congenital anomaly.
- PNH increases the risk of urinary tract infections (UTIs) in early childhood.
- Continuous antibiotic prophylaxis (CAP) is controversially used to prevent UTIs in children with PNH.
Purpose of the Study:
- To determine the incidence of UTIs in children with isolated PNH.
- To compare UTI rates in children with isolated PNH who received CAP versus those who did not.
- To evaluate the effectiveness of CAP in preventing UTIs in this population.
Main Methods:
- A cohort study of 801 children with isolated PNH from the Society for Fetal Urology Hydronephrosis Registry (2008-2020).
- Inclusion criteria: isolated renal pelvis dilation without ureteral or bladder abnormalities.
- Primary outcome: development of UTI, comparing CAP users and non-users, with adjustments for confounding factors.
Main Results:
- The overall UTI rate in children with isolated PNH was 4.2%.
- CAP use was not associated with a significant reduction in UTI risk (4.0% with CAP vs. 4.3% without CAP; P=0.76).
- Independent predictors of UTI included female sex, intact prepuce, and high-grade hydronephrosis.
Conclusions:
- The overall UTI rate in children with isolated PNH is low.
- CAP did not demonstrate a significant benefit in reducing UTI risk in this cohort.
- Clinical decisions regarding CAP for isolated PNH should consider individual patient risk factors.
Background:
Prenatal hydronephrosis (PNH) is one of the most common congenital anomalies and can increase the risk of developing a urinary tract infection (UTI) in the first two years of life. Continuous antibiotic prophylaxis (CAP) has been recommended empirically to prevent UTI in children with PNH, but its use has been controversial.
Objective:
We describe the incidence of UTI in children with isolated PNH of the renal pelvis without ureteral dilation. Our objective was to compare patients receiving and not receiving CAP and determine whether CAP is beneficial at preventing UTI in children with isolated PNH.
Study Design:
Children with confirmed PNH were enrolled between 2008 and 2020 into the Society for Fetal Urology Hydronephrosis Registry. Children with isolated dilation of the renal pelvis without ureteral or bladder abnormality were included. The primary outcome was development of a UTI, comparing patients who were prescribed and not prescribed CAP.
Results:
In this cohort of 801 children, 76% were male, and 35% had high grade hydronephrosis (SFU grades 3-4). CAP was prescribed in 34% of children. The UTI rate among all children with isolated PNH was 4.2%. Independent predictors of UTI were female sex (HR = 13, 95% CI: 3.8-40, p = 0.0001), intact prepuce (HR = 5.1, 95% CI: 1.4-18, p = 0.01) and high grade hydronephrosis (HR = 2.0, 95% CI: 0.99-4.0, p = 0.05; Table) on multivariable analysis. For patients on CAP, the UTI rate was 4.0% compared to 4.3% without CAP (p = 0.76). The risk of UTI during follow-up was not significantly different between patients who received CAP and patients who were not exposed to CAP; adjusting for sex, circumcision status and hydronephrosis grade (HR = 0.72, 95% CI: 0.34-1.5, p = 0.38). In sub-group analysis of patients at higher risk of UTI (uncircumcised males, females and high grade hydronephrosis), CAP use was not associated with a statistically significant reduction in UTI.
Conclusions:
The overall UTI rate in children with isolated PNH is very low at 4.2%. In the overall population of patients with isolated PNH, CAP was not associated with reduction in UTI risk, although the limitations in our study make characterizing CAP effectiveness difficult. Clinicians should consider risk factors prior to placing all patients with isolated PNH on CAP.
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