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ARTICLES:
Eduardo H. Garin, Fernando Olavarria, Victor Garcia Nieto, Blanca Valenciano, Alfonso Campos, and Linda Young
Clinical Significance of Primary Vesicoureteral Reflux and Urinary Antibiotic Prophylaxis After Acute Pyelonephritis: A Multicenter, Randomized, Controlled Study
Pediatrics 2006; 117: 626-632 [Abstract] [Full text] [PDF]
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[Read P3R] Antibiotic prophylaxis probably still has a role in preventing UTIs following acute pyelonephritis
Deepak Ganapathy, Will Carroll   (3 May 2006)

Antibiotic prophylaxis probably still has a role in preventing UTIs following acute pyelonephritis 3 May 2006
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Deepak Ganapathy,
Career Paediatrician
Derbyshire Children's Hospital,
Will Carroll

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Re: Antibiotic prophylaxis probably still has a role in preventing UTIs following acute pyelonephritis

deepakgan{at}yahoo.com Deepak Ganapathy, et al.

We read with interest the paper of Garin et al (1). This paper attempts to answer some of the more important questions that remain about the medium-term management of children admitted following acute pyelonephritis. Whilst we agree with some conclusions of the paper we are a little concerned by the authors suggestion that there is no role for antibiotic prophylaxis in preventing the recurrence of infection in children. The study as described lacks the power to answer this specific question. A recent extension to the CONSORT (Consolidated Standards of Reporting Trials) Statement (2) correctly identifies out the differences in statistical approaches required to demonstrate equivalence or noninferiority in randomised trials. Thus a failure to demonstrate differences between treatment (or non-treatment) arms in this study cannot be equated as a lack of real difference between the groups. This is particularly relevant given the relatively low recurrence rate of urinary tract infections in children on or off prophylaxis.

Furthermore, if we compare the data from children who did or did not receive antibiotic prophylaxis during the study without vesicoureteric reflux (VUR) we see that almost one in four (23.3%, n=14) of children who received no prophylaxis had a subsequent documented urinary tract infection during the follow up period compared with 8.9% (n=4) in treatment group. This shows a trend towards a significant benefit for antibiotic prophylaxis (p=0.052, chi-sqaured test). These observations would suggest to us that in a child without VUR antibiotic prophylaxis is likely to be beneficial in reducing the likelihood of subsequent urinary infection.

For children with VUR the situation is somewhat less clear. Clearly the apparent excess of children with recurrent pyelonephritis in the prophylaxis group (12.9% vs 1.7%) is of potential concern. However, the numbers of children in this study remain small and a much larger study would be required to successfully answer whether children with VUR do not derive benefit from antibiotic prophylaxis.

1. Garin EH, Olavarria F, Nieto VG, Valenciano B, Campos A, Young L. Clinical significance of primary vesiocureteral reflux and unrinary antibiotic prophylaxis after acute pyelonephritis: a mulitcenter, randomised, controlled study. Pediatrics 2006;117:626-632. 2. Piaggio G, Elbourne DR, Altman DG, Pocock SJ, Evans SJW, for the CONSORT group. Reporting of noninferiority and equivalence randomised trials. JAMA 2006;295:1152-1160.

Conflict of Interest:

None declared