Prophylactic antibiotics for children with UTI not associated with reduced risk of recurrence

The use of prophylactic antibiotics, which involves daily administration of antibiotics to children after an initial urinary tract infection, is not associated with reduced risk of recurrent urinary tract infections, but is associated with an increased risk of resistant infections, according to a study in the July 11 issue of JAMA: The Journal of the American Medical Association.

Estimates of cumulative incidence of UTI in children younger than 6 years (3 percent - 7 percent in girls, 1 percent - 2 percent in boys) suggest that 70,000 to 180,000 of the annual U.S. birth cohort will have experienced a UTI by age 6, according to background information in the article. Practice guidelines for after the first UTI in children recommend an imaging study to evaluate for the presence and degree (grade) of vesicoureteral reflux (VUR; a backflow of urine from the bladder into the ureter), a condition present in approximately 30 percent to 40 percent of children with UTI. If the child has VUR, daily antibiotic (destroying or suppressing the growth of microorganisms) treatment is recommended in an attempt to prevent recurrent UTIs. Evidence is limited regarding risk factors for recurrent urinary tract infection (UTI) and the risks and benefits of antibiotic treatment.

Patrick H. Conway, M.D., M.Sc., of the University of Pennsylvania Robert Wood Johnson Clinical Scholars Program, Philadelphia, and colleagues conducted a study to identify risk factors for recurrent UTI and estimate the effectiveness and possibility of resistance of antimicrobials in preventing recurrent UTI. Patients in the study were from a Children's Hospital of Philadelphia supported network of 27 primary care pediatric practices in urban, suburban, and semi-rural areas spanning three states, with children ages birth through 6 years, who were diagnosed with first UTI between July 2001 and May 2006.

Among 74,974 children in the network, 611 had a first UTI and 83 had a recurrent UTI. The researchers found that factors associated with increased risk of recurrent UTI were white race (nearly twice the risk), age 3 to 4 years (2.75 times the risk), age 4 to 5 years (2.5 times the risk), and grade 4 to 5 VUR (4.4 times the risk). Severity of VUR is measured by a grade of 1-5, with 5 being the most severe. Sex, grade 1 to 3 VUR, and other antibiotic exposure had no effect on risk of recurrent UTI. Exposure to prophylactic antibiotics significantly increased the likelihood of resistant infections (7.5 times increased risk).

Given previous findings and the unfavorable risk/benefit ratio demonstrated by the current study, we think it is prudent for clinicians to discuss the risks and unclear benefits of prophylaxis with families as they make family-centered decisions about whether to start prophylactic [antibiotics] or to closely monitor a child without prescribing [antibiotic] prophylaxis after a first UTI," the authors write.

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