Published online December 1, 2008
PEDIATRICS Vol. 122 No. 6 December 2008, pp. 1212-1217 (doi:10.1542/peds.2007-2926)
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ARTICLE

Antibiotic Resistance Patterns of Community-Acquired Urinary Tract Infections in Children With Vesicoureteral Reflux Receiving Prophylactic Antibiotic Therapy

Chi-Hui Cheng, MDa,b, Ming-Horng Tsai, MDc, Yhu-Chering Huang, MD, PhDd,e, Lin-Hui Su, MSe,f, Yong-Kwei Tsau, MDg, Chi-Jen Lin, MDa, Cheng-Hsun Chiu, MD, PhDd,e and Tzou-Yien Lin, MDd,e

a Division of Pediatric Nephrology, Department of Pediatrics
c Department of Pediatrics
d Division of Pediatric Infectious Diseases, Department of Pediatrics, Chang Gung Children's Hospital, Chang Gung Memorial Hospital, Taoyuan, Taiwan
b Graduate Institute of Clinical Medical Sciences, College of Medicine
e College of Medicine, Chang Gung University, Taoyuan, Taiwan
f Department of Clinical Pathology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
g Division of Pediatric Nephrology, Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan

OBJECTIVE. The goal was to examine bacterial antimicrobial resistance of recurrent urinary tract infections in children receiving antibiotic prophylaxis because of primary vesicoureteral reflux.

METHODS. We reviewed data retrospectively for children with documented vesicoureteral reflux in 2 hospitals during a 5-year follow-up period. The patients were receiving co-trimoxazole, cephalexin, or cefaclor prophylaxis or prophylaxis with a sequence of different antibiotics (alternative monotherapy). Demographic data, degree of vesicoureteral reflux, prophylactic antibiotics prescribed, and antibiotic sensitivity results of first urinary tract infections and breakthrough urinary tract infections were recorded.

RESULTS. Three hundred twenty-four patients underwent antibiotic prophylaxis (109 with co-trimoxazole, 100 with cephalexin, 44 with cefaclor, and 71 with alternative monotherapy) in one hospital and 96 children underwent co-trimoxazole prophylaxis in the other hospital. Breakthrough urinary tract infections occurred in patients from both hospitals (20.4% and 25%, respectively). Escherichia coli infection was significantly less common in children receiving antibiotic prophylaxis, compared with their initial episodes of urinary tract infection, at both hospitals. Children receiving cephalosporin prophylaxis were more likely to have an extended-spectrum β-lactamase-producing organism for breakthrough urinary tract infections, compared with children with co-trimoxazole prophylaxis. Antimicrobial susceptibilities to almost all antibiotics decreased with cephalosporin prophylaxis when recurrent urinary tract infections developed. The extent of decreased susceptibilities was also severe for prophylaxis with a sequence of different antibiotics. However, antimicrobial susceptibilities decreased minimally in co-trimoxazole prophylaxis groups.

CONCLUSIONS. Children receiving cephalosporin prophylaxis are more likely to have extended-spectrum β-lactamase-producing bacteria or multidrug-resistant uropathogens other than E coli for breakthrough urinary tract infections; therefore, these antibiotics are not appropriate for prophylactic use in patients with vesicoureteral reflux. Co-trimoxazole remains the preferred prophylactic agent for vesicoureteral reflux.

Key Words: vesicoureteral reflux • prophylactic antibiotics • recurrent urinary tract infection • antibiotic resistance • extended-spectrum β-lactamase

Abbreviations: UTI—urinary tract infection • VUR—vesicoureteral reflux • RR—relative risk • CI—confidence interval • ESBL—extended-spectrum β-lactamase • CGCH—Chang Gung Children's Hospital • NTUH—National Taiwan University Hospital

Accepted Mar 19, 2008.


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