What is the role of antibiotic prophylaxis in the treatment of hydronephrosis and hydroureter?

Updated: Dec 16, 2020
  • Author: Dennis G Lusaya, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Higher rates of urinary tract infections have been reported in children with prenatally diagnosed hydronephrosis compared with the general pediatric population. [30, 31] The risk of infection rises if there is an underlying urologic abnormality, such as VUR or obstructive uropathy, and is greater in girls compared with boys. [32]

As a result, in infants with severe hydronephrosis who are at greater risk for an underlying urologic abnormality, antibiotic prophylaxis is started after delivery until the diagnosis of VUR or obstructive uropathy is excluded.

Antibiotic prophylaxis in children with mild or moderate hydronephrosis confirmed postnatally has not been studied prospectively.

In one retrospective study of 1514 with mild persistent hydronephrosis, the use of prophylactic antibiotics reduced the risk of febrile urinary tract infection in patients who had VUR. [33] Until further prospective studies are conducted, antibiotic prophylaxis should be considered until VCUG has been performed and either the diagnosis of VUR has been made or eliminated.

Antibiotic prophylaxis is not needed in infants with normal postnatal ultrasonography findings. [34]

Four retrospective studies have considered the role of antibiotic prophylaxis in infants with hydronephrosis. Zareba et al analyzed the risk factors for urinary tract infection (UTI) in 376 infants with prenatal hydronephrosis and reported that infants with high-grade hydronephrosis, girls, and uncircumcised boys were at highest risk for UTI. Antibiotic prophylaxis did not decrease the risk in any of the groups studied. [35]

In a systematic review that included 3876 newborns with antenatal hydronephrosis, Braga et al found that infants with high-grade hydronephrosis receiving continuous antibiotic prophylaxis (CAP) had significantly lower UTI rates than those who did not receive an antibiotic regimen (14.6% vs 28.9%). However, the rates for infants with low-grade hydronephrosis were similar (2.2% vs. 2.8%). The researchers cautioned that the level of evidence of available data was moderate to low. [36]

Herz et al reviewed the records of 278 children maintained on CAP and 127 who were not and compared individual characteristics to determine risk factors for UTI. The presence of ureteral dilation, high-grade VUR, and ureterovesical junction obstruction were independent risk factors for development of UTI. CAP had a significant role in reducing UTI in children with the risk factors but was unnecessary otherwise. [37]

Varda et al studied the use of CAP during the interval between birth and initial neonatal imaging in 494 infants with a history of prenatal urinary tract dilation, and these authors concluded that routine CAP may be of limited benefit in most patients in this setting. The incidence of UTI prior to initial neonatal imaging was low, and was not significantly different in study patients who received CAP and those who did not. The ropensity score adjusted odds of developing UTI with CAP versus without was 0.93 (95% CI 0.10-8.32; P = 0.95). [38]

A systematic review from the European Association of Urology/European Society for Paediatric Urology Guidelines Panel found that most studies of CAP had low-to-moderate quality of evidence and high risk of bias. Consequently, the panel concluded that whether CAP is superior to observation in decreasing UTIs remains unproven. However, CAP may be warranted in uncircumcised boys, children with ureteral dilatation, and those with high-grade hydronephrosis, who may be more likely to develop UTI. [39]

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