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Commentary on: Hewitt IK, Pennesi M, Morello W, et al. Antibiotic prophylaxis for urinary tract infection-related renal scarring: a systematic review. Pediatrics 2017;139:e20163145.
Renal scarring is a potentially serious long-term complication of acute pyelonephritis, and the risk increases significantly in children with high-grade vesicoureteral reflux (VUR) and recurrent urinary tract infection (UTI).1 For decades it has been a common practice to use antimicrobial prophylaxis or surgical correction to prevent recurrent UTI and renal scarring in children with VUR. Some recent studies have shown that antimicrobial prophylaxis significantly decreases the risk of UTI recurrence in children with VUR but does not significantly impact the risk of renal scarring when compared with placebo or no treatment.2 3
A review of the literature and a meta-analysis were done to evaluate the effect of antibiotic prophylaxis on UTI-related renal scarring. Medline, Embase and the Cochrane Controlled Trials Register electronic databases were searched for prospective randomised controlled trials (RCTs) performed and published between 1946 and August 2016. Subjects included were identified as 18 years of age or younger with symptomatic or febrile UTIs. Tc dimercaptosuccinic acid scans were performed at entry into the study and at late follow-up to detect new scar formation. The literature search, study characteristics, inclusion and exclusion criteria, and risk of bias assessment were independently evaluated by two authors.
Combined findings of seven RCTs with data on 1427 children revealed that the antibiotic prophylaxis is not indicated for the prevention of renal scarring (pooled risk ratio, 0.83; 95% CI 0.55 to 1.26) after a first or second symptomatic or febrile UTI in otherwise healthy children, nor did it help in a subanalysis restricted to those subjects with VUR (pooled risk ratio, 0.79; 95% CI 0.51 to 1.24). This is in spite of the reported limitations with the studies that were included in this analysis. None of the studies were designed or sufficiently powered with renal scarring as the primary objective. Four of the seven studies had follow-up of only 1 year, which is too short to evaluate for renal scarring. Only one study included patients with grade V VUR, the group with the highest risk of renal scarring, and two studies had only patients with grades I–III VUR, the group with the lowest risk of renal scarring.
This study is yet another addition to the body of existing literature on the ineffectiveness of antimicrobial prophylaxis in the prevention of renal scarring with acute pyelonephritis. Prevention of new renal scarring or worsening of existing scars by recurrent UTI remains a priority in the management of UTI, particularly in high-risk patients. An early diagnosis and prompt treatment of UTI is an effective way to reduce renal scarring associated with VUR and UTI.4 In the absence of any better alternatives, it is prudent to use antimicrobial prophylaxis in patients with high-grade VUR and reserve surgical intervention for those who fail prophylaxis or have other indications for an early surgical correction.5–7 The other determinants for surveillance only versus prophylaxis or surgical intervention include patient age and sex, status of toilet training, coexisting bladder bowel dysfunction, presence of renal scarring, parental preferences, family compliance, tolerance of medication, differential function in the affected kidney if scarred, and presence of complications associated with renal scarring, hypertension in particular.
Implications for practice
Based on the current literature, there is no conclusive evidence to support a routine use of antimicrobial prophylaxis to prevent renal scarring in children with first or second UTI with or without VUR. However, there are enough data to support a ‘selective’ use of antimicrobial prophylaxis to lower the risk of recurrent UTI and possibly scarring in high-risk patients. Appropriately designed clinical trials and research on potential host risk factors, including genetic susceptibility for renal scarring, are needed.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.
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