Is antibiotic prophylaxis effective for the treatment of recurrent pediatric urinary tract infection (UTI)?

Updated: Mar 19, 2019
  • Author: Donna J Fisher, MD; Chief Editor: Russell W Steele, MD  more...
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Many studies have failed to show reductions in the incidence of recurrent UTIs with the use of antibiotic prophylaxis. Several of those studies, however, did not have sufficient statistical power to detect differences or did not have stringent definitions of UTI and inclusion criteria. [50, 51, 52, 53, 54]

A study that evaluated 12 months of prophylaxis with sulfamethoxazole-trimethoprim (SMZ-TMP) compared with placebo to prevent UTI showed a small, but statistically significant, reduction in incidence but did not show any difference in renal scarring. In addition, a significant increase in UTI with SMZ-TMP ̶ resistant organisms occurred in the treatment group. [55]  A meta-analysis that reviewed seven randomized controlled trials that included 1427 febrile UTI patients also found no effect of antibiotic prophylaxis in preventing renal scarring. [62]

A meta-analysis of a selected subset of high-quality, randomized, controlled trials concluded that long-term antibiotics reduce the risk of more symptomatic infections. The benefit is small, however, and must be weighed against the likelihood that future infections may be with bacteria that are resistant to the antibiotic administered. [56]

A study by Selekman et al reported that patients with a history of vesicoureteral reflux being treated with continuous antibiotic prophylaxis were more likely to have a multidrug-resistant urinary tract infection (33% in the antibiotic prophylaxis group vs 6% in the placebo or no treatment group). [64]

Until evidence-based guidelines about the use of suppressive antibacterial therapy after an initial febrile UTI are available, use of antibiotic prophylaxis is based on expert opinion. Antibiotic prophylaxis is more often recommended for children with high-grade reflux (grade 3-5). The current AAP guidelines do not recommend prophylactic antibiotics to prevent UTI recurrences (see table 5, below). [3]

Table 5. Antibiotic Agents to Prevent Reinfection (Open Table in a new window)


Single Daily Dose

Nitrofurantoin *

1-2 mg/kg PO

Sulfamethoxazole and trimethoprim (SMZ-TMP) *

5-10 mg/kg SMZ, 1-2 mg/kg TMP PO


1-2 mg/kg PO

*Do not use nitrofurantoin or sulfa drugs in infants younger than 6 weeks. Reduced doses of an oral first-generation cephalosporin, such as cephalexin at 10 mg/kg, may be used until the child reaches age 6 weeks. Ampicillin or amoxicillin are not recommended because of the high incidence of resistant E coli.

Parents of children with a history of UTI should also be advised to avoid unnecessary use of antibiotics for upper respiratory infections and otitis media. Antibiotics can alter GI and periurethral flora and compromise natural defenses against colonization by pathogenic agents.

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