Prophylactic antibiotics for children with recurrent urinary tract infections

Question 1

What percentage of girls 0-7yo will have a UTI?

Answer 1

8%

Question 2

What percentage of boys 0-7yo will have a UTI?

Answer 2

2%

Question 3

What is the recurrence rate of UTI?

Answer 3

10-30%

Question 4

What are some trials done to study antibiotic prophylaxis for UTI in children?

Answer 4

RIVUR (Randomized Intervention for Children with VCUR)

PRIVENT trial

Montini et al trial

Question 5

What is the evidence for prophylaxis and renal scarring or long term sequelae?

Answer 5

No evidence of prevention with prophylaxis

Question 6

What is an appropriate measure to help decrease UTI?

Answer 6

Manage constipation

Question 7

What are the CPS recommendations regarding antibiotic prophylaxis?

Answer 7

1. Antibiotic prophylaxis is no longer routinely recommended after a UTI but may still be considered when a child is known to have a grade IV or V VUR, or a significant urological anomaly. A large number of children must be treated to prevent one UTI, although this number may be smaller for children with grade IV or V VUR, or a significant urological anomaly. An increasing risk for antibiotic resistance may soon negate the benefits of prophylaxis even in these cases.
2. For cases in which prophylaxis is still used, it should generally last for no longer than three to six months. If the abnormality persists, prophylaxis should be reassessed. Antibiotic resistance increases with prolonged prophylaxis.
3. If the decision is made to offer prophylaxis to children with grade IV or V VUR, or a major urological anomaly, the risks and benefits should be discussed with parents.
4. TMP/SMX or nitrofurantoin are the usual choices for prophylaxis, unless contraindicated or the child has already had urinary isolates test positive for resistance to these drugs. These antibiotics are inexpensive, generally well tolerated and disrupt bowel flora less than most others. Nitrofurantoin is no longer commercially available as a suspension and parents will need to be referred to a compounding pharmacy to obtain it. They can also be advised to crush the pills and mix the powder with yogurt or apple sauce. There is insufficient evidence to recommend a specific dose; however, traditionally, one-quarter to one-third of the daily total treatment dose is given once per day. There are no data on the efficacy of the practice of alternating prophylactic antibiotics on a monthly basis.
5. Prophylaxis should be stopped or changed if an organism that is resistant to the prophylactic antibiotic is identified in a urine culture, even when the culture is believed to be contaminated. That antibiotic is highly likely to be ineffective in preventing UTIs and continuing to use it will promote development of further resistance. If a child has a urinary isolate that is resistant to both TMP/SMX and nitrofurantoin, consider discontinuing prophylaxis.
6. Experience suggests that using broader-spectrum agents for prophylaxis (such as cefixime or ciprofloxacin) often results in a UTI with an organism that is resistant to any remaining oral options for therapy.
7. Cases with grade IV or V VUR, or another significant urological anomaly, should be discussed with or seen by a paediatric nephrologist or urologist.
8. Parents of a child who has had a UTI need to be informed of the signs and symptoms of a recurrence. The threshold should be low for testing for a UTI in such children

Question 8

Who should receive antibiotic prophylaxis?

Answer 8

Consider in cases with grade IV or V VUR or another significant urological anomaly in consultation with peds nephro or urology

Question 9

What is the recommended antibiotic prophylaxis agent?

Answer 9

TMP/SMX or TMP

Question 10

How long should prophylaxis last?

Answer 10

3-6m then re-assess