Antimicrobial prophylaxis for vesicoureteral reflux: which subgroups of children benefit the most?

Area of Science:

• Pediatric Nephrology
• Infectious Diseases
• Clinical Trial Analysis

Background:

• The Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) trial indicated a 50% reduction in recurrent urinary tract infections (UTIs) with long-term antimicrobial prophylaxis.
• However, the observed number needed to treat (NNT) was 10, suggesting a need to identify subgroups who benefit more significantly.

Purpose of the Study:

• To re-analyze RIVUR trial data to identify specific subgroups of children with vesicoureteral reflux (VUR) who experience a greater benefit from long-term antimicrobial prophylaxis.
• To determine subgroups with a lower number needed to treat (NNT) for prophylactic antimicrobial use.

Main Methods:

• Utilized patient-level data from the RIVUR trial.
• Applied penalized regression methods, incorporating baseline age, VUR grade, index UTI type, and bowel-bladder dysfunction (BBD) as covariates to identify beneficial subgroups.

Main Results:

• Identified four subgroups with an NNT of 5 or less: children with grade IV VUR, BBD, and febrile index UTI (1%); children with BBD and febrile index UTI (7%); children with BBD (12%); and children with grade IV VUR (8%).

Conclusions:

• Long-term antimicrobial prophylaxis is particularly relevant for children with BBD (any VUR grade) and those with grade IV VUR (regardless of BBD status).
• Further research is required to clarify the role of prophylactic antimicrobials in managing VUR in children with BBD, pending more detailed treatment information for BBD.