To the Editor.—
Garin et al1 recently reported results of a multicenter randomized trial of antibiotic prophylaxis to prevent recurrent urinary tract infections and renal scarring in children 3 months to 18 years old with a history of pyelonephritis. Among patients with (grades I–III) vesicoureteral reflux (VUR), 7 (12.9%) of 55 of those treated with prophylactic antibiotics developed recurrent pyelonephritis (all with resistant organisms), compared with 1 (1.7%) of 58 of those not treated (P = .029). Renal scars were also more common with antibiotics, occurring in 5 (9.0%) of 55 patients compared with 2 (3.4%) of the 58 controls.
In an accompanying commentary, Wald acknowledged that the study “provided compelling data indicating that urinary tract prophylaxis with currently available agents in children with low grades of VUR (I, II, and III) does not seem to be beneficial.”2 However, she cautioned that the conclusions may not apply to children with higher grades of reflux and stated, “Until such time that there are data to address the usefulness of prophylaxis in these latter cases, we must continue to recommend the performance of the VCUG [voiding cystourethrogram] to determine the presence of VUR and search for strategies to keep the urine free of infection in children with high degrees of VUR.”
This last recommendation seems hard to justify. In a prospective study coauthored by Wald,3 only 4 (1.3%) of 306 children with febrile urinary tract infections had grade IV reflux, and none had grade V. Thus, ∼76 VCUGs would need to be done to identify each child with a grade IV reflux. This seems like a great deal of radiation, cost, and discomfort to identify a few children with an entity that we still do not know how to treat.
Invasive procedures such as the VCUG should be performed only when there is evidence of benefit. Such evidence has never existed for screening for VUR after urinary tract infections.4–6 We now have evidence that the recommended treatment not only does not work but also may be harmful. As Winberg7 wrote about VUR in 1994, “It is psychologically difficult to accept results that suggest that time-honored methods that are generally recommended and applied are of no or doubtful value.”
It has been 12 years; let's get over it! It is well past time to abandon routine VCUGs after urinary tract infections in infants and children.
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- ↵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
- ↵Wald ER. Vesicoureteral reflux: the role of antibiotic prophylaxis. Pediatrics.2006;117 :919– 922
- ↵Hoberman A, Wald ER, Hickey RW, et al. Oral versus initial intravenous therapy for urinary tract infections in young febrile children. Pediatrics.1999;104 :79– 86
- Craig JC, Irwig LM, Knight JF, Roy LP. Does treatment of vesicoureteric reflux in childhood prevent end-stage renal disease attributable to reflux nephropathy? Pediatrics.2000;105 :1236– 1241
- ↵Winberg J. Management of primary vesico-ureteric reflux in children: operation ineffective in preventing progressive renal damage. Infection.1994;22(suppl 1) :S4– S7
- Copyright © 2006 by the American Academy of Pediatrics