Continuous antibiotic prophylaxis (CAP) is the mainstay of treatment and reduces the risk of febrile urinary tract infections (fUTI) in children with VUR. Thus far, there are no clear management guidelines as to whether and when CAP may be safely stopped in cases of children with known VUR after a period of taking it. Discontinuation of CAP or surgical interventions are the potential options often discussed. Here, Abdulfattah et al. looked at the clinical characteristics and predictors of failure in children with persistent primary VUR who stopped CAP without a micturating cystourethrogram confirming VUR resolution. Of 876 children diagnosed with primary VUR during the study interval (January 2012–December 2018), 386 underwent CAP cessation despite no radiographic evidence of VUR resolution. The severity of VUR was 274 (71%) low-grade and 112 (29%) high-grade. CAP cessation occurred at a median age of 39 months, after the children were toilet trained. Only forty-one patients developed a fUTI after CAP cessation. Predictors significantly associated with experiencing a fUTI included female sex and the presence of bladder bowel dysfunction (BBD) symptoms at the time of CAP discontinuation. Other predictors that did not reach statistical significance included a history of breakthrough UTI, high-grade VUR (grade IV / V) and CAP duration. The study findings confirm that discontinuing CAP is a feasible option for selected patients – particularly those who are toilet-trained and exhibit minimal BBD symptoms. The rate of fUTI was significantly higher in girls and those with voiding dysfunction, emphasising the importance of considering these factors when deciding to cease CAP. UTIs develop more frequently in females based on anatomy as well as higher incidence of BBD. Therefore, it is important to use a holistic approach to VUR management and consider both anatomical and functional factors (management options include urotherapy, observation with or without CAP, endoscopic anti reflux surgery (deflux) and ureteral reimplantation). CAP sensation earlier in childhood also merits investigation given that many children receive antibiotics for several years. Earlier discontinuation may be feasible with implementation of pathways for toilet training and bowel management to reduce the risk of bowel-bladder dysfunction.
When can antibiotic prophylaxis be stopped for VUR in children?
Reviewed by Neil Featherstone
A Risk Stratification Model to Predict Febrile Urinary Tract Infection After Cessation of Continuous Antibiotic Prophylaxis in Children With Known Vesicoureteral Reflux.
CONTRIBUTOR
Neil Featherstone
Cambridge University Hospitals NHS Foundation Trust (Addenbrookes Hospital).
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