Prophylaxis for children in VUR

VUR: Vesicoureteral reflux (VUR) is the backflow of urine from the bladder into the upper urinary tract. Management of VUR has been based upon the premise that VUR predisposes patients to acute pyelonephritis.

Rationale:

• assumptions that use of continuous antibiotics results in sterile urine and the continued reflux of sterile urine does not cause renal damage, and the observation that reflux spontaneously resolves in most cases

Evidences:

• Several systemic reviews reporter no difference when compared to placebo
• However, more recent higher quality clinical trials have shown antibiotic prophylaxis reduces the risk of recurrent UTI in young children.

Choice of agents:

• Once daily dose is administered at bedtime
• The dose is ½ to ¼ of the usual therapeutic dose
• The following are single daily doses of commonly used antimicrobial agents:

DRUG	DOSE	RATIONALE
Trimethoprim-sulfamethoxazole or TMP alone	Dosing is based on TMP at 2 mg/kg	Less likely to have recurrent febrile or symptomatic UTI Did not reduce the incidence of renal scarring Increased risk of resistance increased risk of neonatal hyperbilirubinemia
Nitrofurantoin	1 to 2 mg/kg	increased risk of neonatal hyperbilirubinemia
Cephalexin	10 mg/kg	Not generally recommended because of increased risk of resistant organism Only for infants below 2 month, because of adverse effects of sulfanamides, TMP or nitrofurantoin
Ampicillin	20 mg/kg
Amoxicillin	10 mg/kg

Duration:

• Indications of when to discontinue medical therapy are uncertain
• Some experts will only discontinue therapy when the VCUG is negative. Others will discontinue therapy in older children or adolescents with grade I reflux who have been infection free for a year or so
• Long-term follow-up includes annual assessment of linear growth, measurement of blood pressure, and urinalysis

References:
1. www.uptodate.com