2014's Pediatric 'Great Eight': The News You Need to Know

L. Gregory Lawton, MD

Disclosures

December 19, 2014

In This Article

To Prophylax or Not to Prophylax

The scenario is familiar. A cute little girl is diagnosed in your office with her first febrile urinary tract infection (UTI). She is treated and improves, and as part of her work-up is found to have vesicoureteral reflux (VUR).

Enter Hamlet the pediatric urologist: Will trimethoprim/sulfamethoxazole (TMP/SMX) prophylaxis have any effect on preventing recurrences, reducing renal scarring, or altering antimicrobial resistance patterns in the event of treatment failure? The answers, according to the investigators of the Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) trial[8] are yes, no, and yes.

Of 607 children with a febrile UTI with associated VUR seen at one of the RIVUR centers, 302 were randomly assigned to the treatment arm of the study; these patients received 3 mg of trimethoprim plus 15 mg of sulfamethoxazole daily for 2 years. Within those 2 years, 39 children in the prophylaxis cohort developed a recurrent UTI. The placebo arm comprised 305 children, of whom 72 developed a recurrent UTI.

Thus, prophylaxis reduced the risk for recurrent UTI by about 50%. However, there was no difference in the occurrence of renal scarring between the two groups. Moreover, among 87 children with a first recurrence due to E coli, 63% of the isolates in the prophylaxis group were resistant to TMP/SMX, compared with only 19% in the placebo group.

Thus, the question as to how to handle these children is clear as a muddy RIVUR.In 1999, the American Academy of Pediatrics issued a clinical practice guideline on the diagnosis and management of UTIs in febrile children. With the concern about preventing progressive renal damage, consideration of prophylactic antibiotics was standard of care. In 2011, a less aggressive approach was promoted, including reconsideration of the use of prophylactic antibiotics.[9]

Since the publication of this study, the AAP has reaffirmed the 2011 guidelines.[10] The document indicates that on balance, the benefit of daily antibiotic prophylaxis (decrease in recurrent UTIs) is outweighed by both the increased likelihood of antibiotic resistance and the lack of protection from renal scarring.

Large, solid, thoughtful, well-designed, and well-executed studies often provoke more questions than provide answers. Such is the fate of this study. What is the goal of prophylaxis: to prevent recurrent UTIs, or to prevent renal scarring? With antimicrobial resistance on the rise, what are the implications for both the community and the individual patient, given the significant difference in resistance patterns between the prophylaxis and placebo groups? Finally, is there a reliable and reproducible way to reduce renal scarring?

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