Current status of long-term antibiotic prophylaxis for urinary tract infections in children: An antibiotic stewardship challenge

Abstract

Recurrent urinary tract infections (UTIs) in children are associated with development of pyelonephritis and renal scarring. Traditionally, continuous antibiotic prophylaxis (CAP) has been used to prevent recurrent UTI. Recent studies have challenged the efficacy of CAP for preventing renal scarring and have raised concerns about inducing bacterial resistance. This review focuses on studies published between January 2000 and April 2019 and evaluates the use of CAP in children for avoiding recurrent UTIs and renal scarring. A systematic literature search was carried out using the following search terms and related medical subject headings in the MEDLINE electronic database: 'urinary tract infection', 'antimicrobial/antibiotic prophylaxis', and 'children/pediatrics'. Randomized clinical trials (RCTs), original research articles, guidelines, systematic reviews, and meta-analyses describing antibiotic prophylaxis for UTIs were included. A total of 34 RCTs, 9 systematic reviews, and 3 guidelines describing antibiotic prophylaxis were included in this review. The efficacy of CAP for preventing recurrent UTI remains unclear due to non-generalizability of results obtained from suboptimally designed clinical trials. CAP has not been proven as beneficial for preventing new renal scarring in children. Additionally, CAP is associated with increased risk of multidrug resistant infections in children. No conclusive evidence can be drawn from the available clinical data to support routine use of CAP for prevention of renal scarring. Accumulation of evidence from additional well designed studies may result in different conclusions in the future. It is important to identify specific risks for recurrent UTI and ensuing renal injury to ensure more judicious use of CAP.

Keywords: Anti-bacterial agents; Antibiotic prophylaxis; Child; Pediatrics; Urinary tract infections.

Figure 1

Flowchart depicting identification of studies, inclusion, and exclusion assessment for this review. RCTs, randomized clinical trials; UTI, urinary tract infection.

Figure 2

Forest plot depicting risk of urinary tract infections among children receiving prophylactic antibiotics versus those receiving placebo. CI, confidence interval; M–H, Mantel–Haenszel test; PRIVENT, Prevention of Recurrent Urinary Tract Infection in Children with Vesicoureteric Reflux and Normal Renal Tracts; RIVUR, Randomized Intervention for Children with Vesicoureteral Reflux.