Antibiotic Prophylaxis for Urinary Tract Infections in Antenatal Hydronephrosis

Department of Surgery, McMaster University, Hamilton, Ontario, Canada
PEDIATRICS (Impact Factor: 5.47). 12/2012; 131(1). DOI: 10.1542/peds.2012-1870
Source: PubMed


Background and objective:
Continuous antibiotic prophylaxis (CAP) is recommended to prevent urinary tract infections (UTIs) in newborns with antenatal hydronephrosis (HN). However, there is a paucity of high-level evidence supporting this practice. The goal of this study was to conduct a systematic evaluation to determine the value of CAP in reducing the rate of UTIs in this patient population.

Pertinent articles and abstracts from 4 electronic databases and gray literature, spanning publication dates between 1990 and 2010, were included. Eligibility criteria included studies of children <2 years old with antenatal HN, receiving either CAP or not, and reporting on development of UTIs, capturing information on voiding cystourethrogram (VCUG) result and HN grade. Full-text screening and quality appraisal were conducted by 2 independent reviewers.

Of 1681 citations, 21 were included in the final analysis (N = 3876 infants). Of these, 76% were of moderate or low quality. Pooled UTI rates in patients with low-grade HN were similar regardless of CAP status: 2.2% on prophylaxis versus 2.8% not receiving prophylaxis. In children with high-grade HN, patients receiving CAP had a significantly lower UTI rate versus those not receiving CAP (14.6% [95% confidence interval: 9.3-22.0] vs 28.9% [95% confidence interval: 24.6-33.6], P < .01). The estimated number needed to treat to prevent 1 UTI in patients with high-grade HN was 7.

This systematic review suggests value in offering CAP to infants with high-grade HN, however the impact of important variables (eg, gender, reflux, circumcision status) could not be assessed. The overall level of evidence of available data is unfortunately moderate to low.

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    ABSTRACT: Widespread antenatal screening has resulted in increased detection of anomalies of the kidneys and urinary tract. The present guidelines update the recommendations published in 2000. Antenatal hydronephrosis (ANH) is transient and resolves by the third trimester in almost one-half cases. The presence of oligohydramnios and additional renal or extrarenal anomalies suggests significant pathology. All patients with ANH should undergo postnatal ultrasonography; the intensity of subsequent evaluation depends on anteroposterior diameter (APD) of the renal pelvis and/or Society for Fetal Urology (SFU) grading. Patients with postnatal APD exceeding 10 mm and/or SFU grade 3-4 should be screened for upper or lower urinary tract obstruction and vesicoureteric reflux (VUR). Infants with VUR should receive antibiotic prophylaxis through the first year of life, and their parents counseled regarding the risk of urinary tract infections. The management of patients with pelviureteric junction or vesicoureteric junction obstruction depends on clinical features and results of sequential ultrasonography and radionuclide renography. Surgery is considered in patients with increasing renal pelvic APD and/or an obstructed renogram with differential renal function <35-40% or its subsequent decline. Further studies are necessary to clarify the role of prenatal intervention, frequency of follow-up investigations and indications for surgery in these patients.
    Indian Journal of Nephrology 03/2013; 23(2):83-97. DOI:10.4103/0971-4065.109403
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    ABSTRACT: No universal guidelines exist for the management of patients with mild to moderate antenatal hydronephrosis (ANH). Unsurprisingly, practice patterns vary considerably with respect to recommendations for postnatal evaluation and follow-up imaging schedule. Although some clinical tools are available to specifically grade ANH and postnatal hydronephrosis, these are commonly used interchangeably with varying degrees of success. A universal classification system and nomenclature are needed to best identify patients at risk of renal deterioration, UTI and need for surgical intervention. We present our own approach to postnatal risk stratification and management, including recommendations regarding serial ultrasonography schedule, prophylactic antibiotics, voiding cystourethrogram and renal scintigraphy.
    Nature Reviews Urology 08/2013; 10(11). DOI:10.1038/nrurol.2013.172 · 4.84 Impact Factor
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    ABSTRACT: Antenatal hydronephrosis (ANH) is a common finding on prenatal ultrasound that can be a sign of a variety of urologic conditions.Most cases of ANH are mild to moderate with the most common cause being transient physiologic dilation, which usually is of no clinical significance. However, there are some infants who have a history of ANH (usually severe) who are at increased risk for febrile urinary tract infections, undergo surgical intervention, and develop chronic kidney disease. It is useful to have an understanding of the possible urologic diagnoses that can lead to ANH and it is critical to recognize the patients who have ANH who require urgent or semiurgent evaluation soon after birth by a pediatric urologist and nephrologist. In addition, it is important to select appropriate postnatal imaging studies and to follow-up based on the clinical scenario and to prescribe prophylactic antibiotics to those patients most likely to benefit. © 2013 by the American Academy of Pediatrics. All rights reserved.
    NeoReviews 11/2013; 14(11):e551-e561. DOI:10.1542/neo.14-11-e551
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