Antibiotic Prophylaxis in Pediatric Urology: An Update

Conflicting views of physicians and surgeons concerning pediatric urinary tract infection: a comparative review

BACKGROUND

A first febrile urinary tract infection (UTI) is a common condition in children, and pathways of management have evolved over time.

OBJECTIVE

To determine the extent to which pediatricians and surgeons differ in their investigation and management of a first febrile UTI, and to evaluate the justifications for any divergence of approach.

MATERIALS AND METHODS

A literature search was conducted for papers addressing investigation and/or management following a first febrile UTI in children published between 2011 and 2021. Searches were conducted on Medline, Embase, and the Cochrane Controlled Trials Register. To be eligible for inclusion, a paper was required to provide recommendations on one or more of the following: ultrasound (US) and voiding cystourethrogram (VCUG), the need for continuous antibiotic prophylaxis and surgery when vesicoureteral reflux (VUR) was detected. The authorship required at least one pediatrician or surgeon. Authorship was categorized as medical, surgical, or combined.

RESULTS

Pediatricians advocated less imaging and intervention and were more inclined to adopt a "watchful-waiting" approach, confident that any significant abnormality, grades IV-V VUR in particular, should be detected following a second febrile UTI. In contrast, surgeons were more likely to recommend imaging to detect VUR (p<0.00001), and antibiotic prophylaxis (p<0.001) and/or surgical correction (p=0.004) if it was detected, concerned that any delay in diagnosis and treatment could place the child at risk of kidney damage. Papers with combined authorship displayed intermediate results.

CONCLUSION

There are two distinct directions in the literature regarding the investigation of an uncomplicated first febrile UTI in a child. In general, when presented with a first febrile UTI in a child, physicians recommend fewer investigations and less treatment, in contrast to surgeons who advocate extensive investigation and aggressive intervention in the event that imaging detects an abnormality. This has the potential to confuse the carers of affected children.

Effect of continuous antibiotic prophylaxis in children with postoperative JJ stents: A prospective randomized study

OBJECTIVE

We aimed to investigate the effectiveness of continuous antibiotic prophylaxis (CAP) in patients with JJ stent and tried to identify the group that could specifically benefit from CAP by a prospective randomized study.

METHODS

A prospective, randomized, controlled, non-blind, non-placebo study was performed in a single center.A total of 105 patients who underwent surgery with JJ stent (PNL, URS, pyeloplasty, UNC) were randomized into two groups. 53 patients in Group A received CAP and 52 patients in Group B were controlled without CAP, during the presence of a JJ stent. Patients with external stents, nephrostomy tubes, indwelling long-term urethral catheters were excluded. History of preoperative use of CAP and lower urinary tract symptoms were noted. Trimethoprim/sulfamethoxazole (TMP/SMX) was used as the initial choice of antibiotic however if there was a history of antibiotic resistance in previous urinary cultures, Nitrofurantoin was administrated. Urinary cultures were obtained before surgery and before stent extraction. JJ stents were sent to culture. Symptomatic febrile urinary tract infections with positive urine cultures (10⁵ CFU on a clean catch or 10³with urethral catheterization) were compared between groups.

DISCUSSION

Our study has some limitations; the study is the single-center, we did not follow-up of patients in terms of scar, there were low number of uncircumcised patients, multiple types of surgical procedures were performed. JJ stent is a frequently used instrument in children. Unfortunately, any randomized prospective on antibiotics administration while using a JJ stent is not available in the current literature. We hope our research will contribute to the existing literature and cause a significant change in clinical practice.

RESULTS

The mean age among all patients was 4.8 ± 3.9 years. The mean length of time jj stents stayed inside was 16.34 ± 6.45 days in group A and 15.29 ± 7.71 days in group B. The incidence of febrile urinary tract infections with CAP was significantly reduced (3.8% vs. 19% (p 0.015)). Multivariate regression analysis revealed that a positive history for preop febrile urinary tract infections and/or LUTS has a significantly higher association with the incidence of febrile urinary tract infecitons.

CONCLUSIONS

CAP in the presence of JJ stents reduced the incidence of febrile urinary tract infections in a short period, especially in children with the previous history of febrile urinary tract infections and lower urinary tract symptoms.

From Research Question to Conducting a Randomized Controlled Trial on Continuous Antibiotic Prophylaxis in Prenatal Hydronephrosis: A Rational Stepwise Process

INTRODUCTION AND OBJECTIVES

Continuous antibiotic prophylaxis (CAP) use to prevent urinary tract infections (UTI) in infants with prenatal hydronephrosis (HN) remains controversial. Lack of consensus guidelines and diverse practice patterns for postnatal management of HN highlight the dire need for higher level of evidence studies. Herein, we aim to describe the steps from developing a well-defined research question to execute a multicentered randomized controlled trial (RCT) to address the issue of CAP use in patients with prenatal HN.

MATERIALS AND METHODS

The steps involved were (1) choosing the proper research question, (2) survey of practice patterns and establishing clinical equipoise, (3) systematic review of the literature, (4) reviewing own practice, (5) longitudinal prospective study, (6) pilot study, (7) cost-utility analysis, and (8) definitive RCT (clinical trials registry number: NCT01140516). An update of our previous systematic review was conducted using two electronic databases and gray literature from 2010 to 2015. Eligibility criteria included studies of children <2 years old with postnatally confirmed prenatal HN, receiving CAP or not, and reporting on development of UTIs, capturing information on voiding cystourethrogram result and HN grade. Full-text screening was conducted by two independent reviewers. UTI rates in patients with high-grade HN were compared across different study designs. Finally, blinded comparative analysis of UTI rates between placebo and treatment groups was carried out using chi-square test.

RESULTS

UTI rates in patients with high-grade HN by their respective study design were: 25% for systematic review, 20% for retrospective study, 21% for prospective and pilot studies, and 13% for the definitive RCT thus far. Regardless of the type of study design, patients with hydroureteronephrosis had significantly higher (threefold to sixfold) UTI rates than those with isolated HN. Our updated systematic review yielded 486 citations, of which 9 (n = 1987 infants) observational studies met eligibility criteria.

CONCLUSION

UTI rates in patients with high-grade HN dropped from 25% in observational studies to 13% in our RCT. This decline in UTI rate demonstrates that study designs lacking strategies to minimize bias are more prone to overestimate treatment effects. These findings highlight the importance of conducting methodologically sound RCTs to answer clinically meaningful questions, such as the one presented here.

Long-term, low-dose prophylaxis against urinary tract infections in young children

Urinary tract infection (UTI) affects about 2 % of boys and 8 % of girls during the first 6 years of life with Escherichia coli as the predominant pathogen. Symptomatic UTI causes discomfort and distress, and carries a risk of inducing renal damage. The strong correlation between febrile UTI, dilating vesicoureteral reflux (VUR), and renal scarring led to the introduction of antibiotic prophylaxis for children with VUR to reduce the rate of UTI recurrence. It became common practice to use prophylaxis for children with VUR and other urinary tract abnormalities. This policy has been challenged because of a lack of scientific support. Now, randomized controlled studies are available that compare prophylaxis to no treatment or placebo. They show that children with normal urinary tracts or non-dilating VUR do not benefit from prophylaxis. Dilating VUR may still be an indication for prophylaxis in young children. After the first year of life, boys have very few recurrences and do not benefit from prophylaxis. Girls with dilating VUR, on the other hand, are more prone to recurrences and benefit from prophylaxis. There has been a decline in the use of prophylaxis due to questioning of its efficacy, increasing bacterial resistance, and a propensity to low adherence to medication. Alternative measures to reduce UTI recurrences should be emphasized. However, in selected patients carefully followed, prophylaxis can protect from recurrent UTI and long-term sequelae. 1. There is a strong correlation between UTI, VUR, and renal scarring. 2. Children with normal urinary tracts or non-dilating VUR do not benefit from prophylaxis. 3. Young children, mainly girls, with dilating VUR are at risk of recurrent UTI and acquired renal scarring and seem to gain from antibiotic prophylaxis. 4. Increasing bacterial resistance and low adherence with prescribed medication is a major obstacle to successful antibiotic prophylaxis.

Antibiotic prophylaxis for urinary tract infections in antenatal hydronephrosis

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.