There has been intense discussion on the effectiveness of continuous antibiotic prophylaxis for children with vesicoureteral reflux, and randomized, controlled trials are still needed to determine the effectiveness of long-term antibiotics for the prevention of acute pyelonephritis. In this multicenter, open-label, randomized, controlled trial, we tested the effectiveness of antibiotic prophylaxis in preventing recurrence of pyelonephritis and avoiding new scars in a sample of children who were younger than 30 months and vesicoureteral reflux.
One hundred patients with vesicoureteral reflux (grade II, III, or IV) diagnosed with cystourethrography after a first episode of acute pyelonephritis were randomly assigned to receive antibiotic prophylaxis with sulfamethoxazole/trimethoprim or not for 2 years. The main outcome of the study was the recurrence of pyelonephritis during a follow-up period of 4 years. During follow-up, the patients were evaluated through repeated cystourethrographies, renal ultrasounds, and dimercaptosuccinic acid scans.
The baseline characteristics in the 2 study groups were similar. There were no differences in the risk for having at least 1 pyelonephritis episode between the intervention and control groups. At the end of follow-up, the presence of renal scars was the same in children with and without antibiotic prophylaxis.
Continuous antibiotic prophylaxis was ineffective in reducing the rate of pyelonephritis recurrence and the incidence of renal damage in children who were younger than 30 months and had vesicoureteral reflux grades II through IV.
"In fact, the highest percentage of patients with pyelonephritis in this study comprised those who had VUR and were on antibiotics. In 2008, Pennesi reported on 100 children under 30 months of age with grades 2–4 VUR, diagnosed after pyelonephritis, who were randomized to antibiotics or observation for 2 years, and then all observed without antibiotics for an additional 2 years (13). There was no significant difference in the incidence of pyelonephritis on or off antibiotics (36% vs. 30%, respectively). "
[Show abstract][Hide abstract] ABSTRACT: Approaches to the management of vesicoureteral reflux (VUR) in children have changed rapidly in recent years. Multiple studies published over the last decade have contributed to these changes by challenging the dogma that all children with reflux require and benefit from continuous antibiotic prophylaxis. The advent and wide acceptance of endoscopic treatment for VUR has also contributed to these changes. Although new guidelines for VUR management have recently been proposed, they are broad and relatively non-specific. Many physicians and parents remain unsure which children are at risk from their VUR, and which would benefit from antibiotic prophylaxis or surgical intervention.
A literature search, followed by an additional search based on bibliographies, was performed for articles reporting on VUR and the utility of antibiotic prophylaxis for its treatment, as well as the chance of spontaneous resolution.
Articles selected for review included those that provided information to assist physicians in determining if a child with VUR is at increased risk of pyelonephritis or persistent VUR, and would benefit from intervention. Particular emphasis was placed on recent prospective, randomized trials in children with VUR.
Because of the multiple factors affecting risk in a child with VUR, specific guidelines for intervention cannot be provided. However, an accurate understanding of these risk factors will help the physician and parents to develop a more individualized management plan for a child with VUR.
"This data showed that those patients, who had shown initially VUR correction, but developed febrile UTI in the long-term followup, require prompt reevaluation in order to rule out VUR recurrence. Furthermore, in the light of recent reports regarding the low effectiveness of antibiotic prophylaxis in children with VUR, the question is raised whether we have an optimal tissue augmenting substance which has a durable long-term efficacy and a good safety profile    "
[Show abstract][Hide abstract] ABSTRACT: Purpose. We reviewed our 20 years of experience and the current literature regarding the long-term outcome of endoscopic treatment of vesicoureteric reflux (VUR) using the different tissue bulking substances with a special emphasis on the long-term efficacy. Material and Methods. Our own experience and the current literature on the long-term results after endoscopic treatment using various bulking agents were reviewed. Results. Short-term data following endoscopic treatment of VUR is similar to the various substances and comparable in the majority of the series to the success rate following open surgery. Recently, a relatively high recurrence rate was noticed especially with the use of dextranomer hyaluronic acid (Dx/HA) as a tissue augmenting material which raises the need for further search for alternative substances. Conclusions. Unfortunately, there is a significant shortage of evidence-based literature on the long-term followup after endoscopic correction of reflux with various substances. No doubt, there is a high recurrence rate during long-term followup after Dx/HA injection, and there is probably lack of proper evaluation regarding the long-term efficacy of other bulking materials. These facts demand long-term close observation and long-term studies beyond the routine protocols following endoscopic treatment of VUR and the correct parental counseling upon the endoscopic correction.
Advances in Urology 04/2011; 2011:309626. DOI:10.1155/2011/309626
"All of the studies in this analysis were compromised by lack of a placebo group and by varying methods of urine collection. Pennesi et al. studied the benefit of antibiotic prophylaxis in preventing pyelonephritis in children with grades IIeIV VUR  diagnosed after an initial episode of pyelonephritis . Fifty patients were randomized to each arm. "
[Show abstract][Hide abstract] ABSTRACT: The current management of vesicoureteral reflux (VUR) focuses on the prevention of urinary tract infections (UTI), with curative surgery being limited to those children that fail conservative measures. This is based on the assumption that UTIs are preventable with the use of prophylatic antibiotics, leading to reduction of renal scarring, and the possibility that VUR in children can resolve spontaneously.
Review of the recent literature has demonstrated a growing concern that antibiotic prophylaxis may not lead to prevention of UTIs. Additionally, data indicate that renal scarring may not be preventable with antibiotic prophylaxis or even surgical correction of VUR. An overview of all of the current controversies is presented in this paper.
Does antibiotic prophylaxis lead to reduction in UTIs in children with VUR? To address this question, the National Institutes of Health have developed a randomized placebo-controlled study of children with VUR (the RIVUR Study), identified following the development of a UTI.
There are far reaching consequences of the results of the RIVUR Study. If antibiotic prophylaxis does not prevent UTI in children with VUR, or lead to reduction in renal scarring, does identification of VUR provide any benefits? Perhaps appropriate treatment of UTI may be all that is necessary for preserving renal function. Final answers will have to wait until the completion of this study.
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