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Vesicoureteral reflux (VUR) in children: antibiotic prophylaxis is not effective in preventing complications

Continuous antibiotic prophylaxis is not effective in preventing severe complications such as acute pyelonephritis (inflammation of kidney and renal pelvis) in children with vesicoureteral reflux (VUR).

This result stems from a randomized controlled trial led by the Institute of Child Health Burlo Garofolo (ICHBG) in Trieste (Italy) that lasted 6 years (2 years of investigation and 4 years of follow-up).

This study put an end to a long-lasting debate on the effectiveness of antibiotic prophylaxis in preventing the recurrences of urinary tract infections. The study, performed in 6 Paediatrics Hospitals in Northern Italy (Pordenone, Monfalcone, San Daniele, Tolmezzo, Cesena and Bologna), was published in the journal Pediatrics.

Vesicoureteral reflux is quite a common congenital anomaly in infancy. It is caused by the delay in the vesico-ureteral junction maturation that causes urine to flow towards the kidneys. This event may promote the onset of urinary tract infections that might be complicated by pyelonephritis, a severe and often recurrent renal inflammation. The disease usually resolves by the age of 10-12 years even in more severe cases, but in the meantime recurrent episodes of pyelonephritis may damage the renal function and lead to chronic renal failure.

Despite the lack of evidence about a causative relationship between VUR and recurrent pyelonephritis, the common clinical approach to vesicoureteral reflux was based on the use of long (many years) and continuous antibiotic prophylaxis even in asymptomatic children. It was commonly thought that this treatment could avoid renal involvement.

The multicentric study coordinated by the Institute of Child Health Burlo Garofolo in Trieste proves the ineffectiveness of this strategy and confirms the hypothesis that the better way to treat pyelonephritis in children with VUR is an early diagnosis followed by a single cycle of a specific antibiotic.

As Marco Pennesi, head of the Nephrology Unit of the Pediatric Department of ICHBG, says: “This trial puts two head points in the treatment of pyelonephritis in children with VUR. First of all, it shows that antibiotic prophylaxis is unhelpful in preventing acute recurrent renal inflammation; second of all, it study confirms that the standard approach (antibiotic prophylaxis) does not modify the natural history of the disease as it doesn’t significantly lower the incidence of renal damage evidenced by the presence of renal scars. Moreover, in contrast to other investigations that examined very heterogeneous populations (infants aged six months to boys of 18 years), this trial clearly spots the class of age at higher risk for complications, the one that really needs an early intervention: children under 30 months of age”

The trial enrolled 100 children under 30 months of age affected by proved VUR, who were randomized to be treated or not with the antibiotic prophylaxis. At the end of the study, the researchers didn’t find any significant difference between the two groups in terms of pyelonephritis or presence of more renal scars.

“Data collected in these 6 years – states Alessandro Ventura, Director of the Pediatric Clinic of the University of Trieste, located at the ICHBG – show that VUR by itself is not a risk factor for recurrent pyelonephritis as previously thought. Now it is of critical importance to add this new piece of evidence to the paediatric guidelines and to make Paediatricians aware of these new findings”.

Cristina Serra | alfa
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