Published online November 1, 2006
PEDIATRICS Vol. 118 No. 5 November 2006, pp. 2251a-2252 (doi:10.1542/peds.2006-2235)
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LETTER TO THE EDITOR

Much Pain, Little Gain From Voiding Cystourethrograms After Urinary Tract Infection: In Reply

Ellen R. Wald, MD
Department of Pediatrics
University of Wisconsin Children's Hospital
Madison, WI 53792

Although Garin et al1 showed that urinary tract infection prophylaxis with currently available agents did not seem beneficial in children with low degrees of reflux (I, II, and III), the study suffered from many methodologic flaws. Antimicrobial treatment of the acute episode was not standardized, and a placebo was not administered to the control group. Neither subjects nor physicians were blinded to the treatment assignment. The microbiology of initial and breakthrough episodes of urinary tract infection were not provided. Children who experienced 2 episodes of pyelonephritis during the year were excluded from analysis, as were children who were not adherent to their prophylactic therapy. Most worrisome of the methodologic problems, which weakens the study, was the performance of the primary analysis only on patients who completed the 1-year follow-up; an intention-to-treat analysis was not performed. Additional studies that systematically address this important question are warranted before the practice of performing voiding cystourethrograms after a first febrile urinary tract infection in young children is abandoned. A large, prospective, placebo-controlled, multicenter clinical trial assessing the effectiveness of antimicrobial prophylaxis in patients with reflux is being funded by the National Institutes of Health and is about to start. I am waiting to decide whether to change practice until the results of this trial are available, and I would advise others to do the same.

REFERENCE

  1. Garin EH, Olavarria F, Garcia Nieto V, Valenciano B, Campos A, Young L. Clinical significance of primary vesicoureteral reflux and urinary antibiotic prophylaxis after acute pyelonephritis: a multicenter, randomized, controlled study. Pediatrics. 2006;117 :626 –632[Abstract/Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics




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