PEDIATRIC UROLOGY

Antibiotic prophylaxis for the prevention of recurrent urinary tract infection in children with low grade vesicoureteral reflux: results from a prospective randomized study
Roussey-Kesler G, Gadjos V, Idres N, Horen B, Ichay L, Leclair MD, Raymond F, Grellier A, Hazart I, de Parscau L, Salomon R, Champion G, Leroy V, Guigonis V, Siret D, Palcoux JB, Taque S, Lemoigne A, Nguyen JM, Guyot C
Medical Pediatric Clinic, Hospital Center and University of Nantes, Nantes, France
J Urol. 2008; 179: 674-9; discussion 679.

• Purpose: Antibiotic prophylaxis is given to children at risk for urinary tract infection. However, evidence concerning its effectiveness in grade I to III vesicoureteral reflux is lacking. The objective of this study was to determine whether antibiotic prophylaxis reduces the incidence of urinary tract infection in young children with low grade vesicoureteral reflux.
• Materials and Methods: Children 1 month to 3 years old with grade I to III vesicoureteral reflux were assigned randomly to receive daily cotrimoxazole or no treatment, and followed for 18 months. A urinary tract infection constituted an exit criterion. Infection-free survival rates were calculated using the Kaplan-Meier method and compared using the log rank test.
• Results: A total of 225 children were enrolled in the study. Distribution of gender, age at inclusion and reflux grade were similar between the 2 groups. There was no significant difference in the occurrence of urinary tract infection between the 2 groups (17% vs. 26%, p = 0.2). However, a significant association was found between treatment and patient gender (p = 0.017). Prophylaxis significantly reduced urinary tract infection in boys (p = 0.013), most notably in boys with grade III vesicoureteral reflux (p = 0.042).
• Conclusions: These data suggest that antibiotic prophylaxis does not reduce the overall incidence of urinary tract infection in children with low grade vesicoureteral reflux. However, such a strategy may prevent further urinary tract infection in boys with grade III reflux.
  
  
• Editorial Comment
  This study again tries to demonstrate whether prophylactic antibiotics are of value in refluxing patients and could not show a significant difference for prophylaxis in mild refluxing patients, except in Grade III boys.
  I have concerns with urine samples of bag collections and their lack of attempt to define poor compliance. Previous studies have either measured drug excretion in the urine or sensitivity of the bacteria to the antibiotic that the patient was taking and 27% of the E-coli infections in the prophylactic group were sensitive to the medication that the patient was supposed to be taking. Other studies have suggested up to one-third of patients and parents are non-compliant with recommended prophylactic treatments.
  I must admit that I do struggle with data such as this, where 17% of the treatment patients had an infection and 26% of the no treatment had an infection. This brings into question the difference between statistical significance and clinical significance, and makes it hard to recommend no treatment over prophylactic antibiotics. It points out how difficult it is to do a large study with sufficient number of patients to leave the readers without any doubt of the proper treatment. It is tempting to make the conclusion that no treatment is the right answer but I wonder whether the more cautious approach is to recommend early surgical treatment of reflux, which has been shown to protect kidneys from scarring, even though it does not alter the recurrent UTI rate.

Dr. Brent W. Snow
Division of Urology
University of Utah Health Sci Ctr
Salt Lake City, Utah, USA
E-mail: brent.snow@hsc.utah.edu