Antibiotics and surgery for vesicoureteric reflux: a meta-analysis of randomised controlled trials

Abstract

Aims: To evaluate the benefits and harms of treatments for vesicoureteric reflux in children.

Methods: Meta-analyses of randomised controlled trials using a random effects model. Main outcome measures were incidence of urinary tract infection (UTI), new or progressive renal damage, renal growth, hypertension, and glomerular filtration rate.

Results: Eight trials involving 859 evaluable children comparing long term antibiotics with surgical correction of reflux (VUR) and antibiotics (seven trials) and antibiotics compared with no treatment (one trial) were identified. Risk of UTI by 1-2 and 5 years was not significantly different between surgical and medical groups (relative risk (RR) by 2 years 1.07; 95% confidence interval (CI) 0.55 to 2.09, RR by 5 years 0.99; 95% CI 0.79 to 1.26). Combined treatment resulted in a 60% reduction in febrile UTI by 5 years (RR 0.43; 95% CI 0.27 to 0.70) but no concomitant significant reduction in risk of new or progressive renal damage at 5 years (RR 1.05; 95% CI 0.85 to 1.29). In one small study no significant differences in risk for UTI or renal damage were found between antibiotic prophylaxis and no treatment.

Conclusion: It is uncertain whether the identification and treatment of children with VUR confers clinically important benefit. The additional benefit of surgery over antibiotics alone is small at best. Assuming a UTI rate of 20% for children with VUR on antibiotics for five years, nine reimplantations would be required to prevent one febrile UTI, with no reduction in the number of children developing any UTI or renal damage.

Figure 1

Meta-analyses of relative risk (random effects model) of urinary tract infections. Subtotals pertain to all urinary tract infections at 2 years post-entry (outcome 01), all urinary tract infections at 5 years post-entry (outcome 02), and symptomatic (febrile) urinary tract infections at 5 years post-entry (outcome 03). BRS, Birmingham Reflux Study; IRS Europe, European arm of the International Reflux Study; IRS US, United States arm of the International Reflux Study. Trials are shown ordered by study weights. No heterogeneity was shown using Cochran's Q statistic (χ² analysis with degrees of freedom, df). The test statistics Z indicate that there were no significant differences between the combined treatment group and the antibiotic only group of patients with vesicoureteric reflux except for febrile urinary tract infection (outcome 03).

Figure 2

Meta-analyses of relative risk (random effects model) for the development of renal parenchymal abnormalities diagnosed by intravenous pyelogram. Subtotals pertain to new defects at 2 and 5 years (outcomes 01 and 03), progression of those previously identified at 2 and 5 years post-entry (outcomes 02 and 04), and all defects, both new and progressive, at both 2 and 5 years (outcomes 05 and 06). BRS, Birmingham Reflux Study; IRS Europe, European arm of the International Reflux Study; IRS US, United States arm of the International Reflux Study. Trials are shown ordered by study weights. No heterogeneity was shown using Cochran's Q statistic (χ² analysis with degrees of freedom, df). The test statistics Z indicate that there were no significant differences between the combined treatment group and the antibiotic only group of patients with vesicoureteric reflux.