Antibiotic Prophylaxis Does Not Lower Rate of Recurrent UTI in Children

In fact, prophylaxis is associated with increased risk for resistant urinary tract infection.

The 1999 American Academy of Pediatrics practice guideline recommends that children with a first urinary tract infection (UTI) undergo imaging to determine the presence and grade of vesicoureteral reflux, which is found in 30% to 40% of children with UTI. The guideline recommends that children with vesicoureteral reflux be given daily antibiotic prophylaxis to suppress recurrent UTI and, theoretically, to prevent renal scarring, but there is scant scientific support for this stance. Therefore, investigators sought to identify risk factors for recurrent UTI and resistant UTI and to assess the value of antibiotic prophylaxis against recurrent UTI in a cohort study of children 6 years or younger.

Among nearly 75,000 children seen at 27 primary care pediatric practices from 2001 to 2006, the incidence of first UTI was 0.7%, the rate of recurrent UTI was 12%, and the cumulative incidence of UTI was 4.2% per person-year. Factors that increased the risk for recurrent UTI were white race (hazard ratio, 1.97); age 3–4 years (HR, 2.75); age 4–5 years (HR, 2.47); and grade 4–5 vesicoureteral reflux (HR, 4.38). Antibiotic prophylaxis was not associated with lower risk of recurrent UTI (HR, 1.01) but was a risk factor for antibiotic resistance among children with recurrent UTI (HR, 7.50).

Comment: This is the first large cohort study to determine the incidence of and risk factors for recurrent UTI in children. The noteworthy discovery that antibiotic prophylaxis does not help prevent recurrent UTI and that, in fact, it leads to an increase in resistant strains in recurrent UTI episodes strikes down conventional dogma. For children 6 years old with primary or recurrent UTI, treat the primary disease, but do not initiate or recommend daily antibiotic prophylaxis.

— John A. Marx, MD, FAAEM, FACEP

Published in Journal Watch Emergency Medicine July 27, 2007

Citation(s):
Conway PH et al. Recurrent urinary tract infections in children: Risk factors and association with prophylactic antimicrobials. JAMA 2007 Jul 11; 298:179-86.