Paediatric Recurrent UTI

• routine surveillance of asymptomatic children did not enhance identification of true UTI episodes 
• suggest antimicrobial prophylaxis in children without vesicoureteral reflux (VUR) who have frequent recurrent UTIs (three febrile UTIs in six months or four total UTIs in one year).
•  Antimicrobial prophylaxis also may be warranted for children with more severe initial UTI episodes or those with additional UTI risk factors (eg, bladder and bowel dysfunction)

Choice of Antibiotic
Treatment:

Prophylaxis:

Agent	Single Daily Dose
Nitrofurantoin *	1-2 mg/kg PO
Sulfamethoxazole and trimethoprim (SMZ-TMP) *	5-10 mg/kg SMZ, 1-2 mg/kg TMP PO
Trimethoprim	1-2 mg/kg PO
*Do not use nitrofurantoin or sulfa drugs in infants younger than 6 weeks. Reduced doses of an oral first-generation cephalosporin, such as cephalexin at 10 mg/kg, may be used until the child reaches age 6 weeks. Ampicillin or amoxicillin are not recommended because of the high incidence of resistant E coli.

• Duration: for six months
• can be discontinued if no infection occurs during the period of prophylaxis
• if infection recurs, resumption of prophylaxis may be warranted

Evidence:

• most studies included only children with VUR
• A meta-analysis of individual data restricted to young children 2 to 24 months of age without VUR did not detect a benefit for prophylaxis in preventing recurrence
• In two companion studies of children with and without VUR who were followed prospectively for two years, the rate of reinfection was lowest in children with VUR who were randomized to prophylaxis (12 percent), highest in children with VUR randomized to placebo (25 percent)
• A study that evaluated 12 months of prophylaxis with sulfamethoxazole-trimethoprim (SMZ-TMP) compared with placebo to prevent UTI showed a small, but statistically significant, reduction in incidence but did not show any difference in renal scarring. In addition, a significant increase in UTI with SMZ-TMP ̶ resistant organisms occurred in the treatment group
• Until evidence-based guidelines about the use of suppressive antibacterial therapy after an initial febrile UTI are available, use of antibiotic prophylaxis is based on expert opinion

Cranberry Juice

• do not routinely suggest cranberry juice for the prevention of recurrent UTI in children. 
• In a meta-analysis of 13 studies including children and adults (n = 2462), cranberry products did not reduce the occurrence of symptomatic UTI compared with placebo, water, or no treatment
• Although cranberry juice in moderation is unlikely to be harmful, excessive intake may contribute to dental caries, diarrhea, and obesity

Circumcision

• Consider circumcision of male neonates. 
• The AAP policy statement on circumcision is that “the health benefits of newborn male circumcision outweigh the risks and that the procedure's benefits justify access to this procedure for families who choose it

References:

1. www.uptodate.com
2. http://emedicine.medscape.com/article/969643-treatment#d13
3. http://www.aafp.org/afp/2011/0215/p409.html