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UTI Prophylaxis doesn’t Work
Conway PH, Cnaan A, Zaoutis T, et al. Recurrent Urinary Tract Infections in Children: Risk Factors and Association With Prophylactic Antimicrobials. JAMA (Jul 11, 2007);298:179-186. FULL TEXT | PDF
Objectives. To identify risk factors for recurrent UTI in a pediatric primary care cohort, to determine the association between antimicrobial prophylaxis and recurrent UTI, and to identify the risk factors for resistance among recurrent UTIs.
Design, Patients, and Setting. From a network of 27 primary care pediatric practices in urban, suburban, and semirural areas spanning 3 states, a cohort of children aged 6 years or younger who were diagnosed with first UTI between July 1, 2001, and May 31, 2006, was assembled. Time-to-event analysis was used to determine risk factors for recurrent UTI and the association between antimicrobial prophylaxis and recurrent UTI, and a nested case-control study was performed among children with recurrent UTI to identify risk factors for resistant infections.
Main Outcome Measures. Time to recurrent UTI and antimicrobial resistance of recurrent UTI pathogens.
Results . Among 74 974 children in the network, 611 (0.007 per person-year) had a first UTI and 83 (0.12 per person-year after first UTI) had a recurrent UTI. In multivariable Cox time-to-event models, factors associated with increased risk of recurrent UTI included white race (0.17 per person-year; hazard ratio [HR], 1.97; 95% confidence interval [CI], 1.22-3.16), age 3 to 4 years (0.22 per person-year; HR, 2.75; 95% CI, 1.37-5.51), age 4 to 5 years (0.19 per person-year; HR, 2.47; 95% CI, 1.19-5.12), and grade 4 to 5 vesicoureteral reflux (0.60 per person-year; HR, 4.38; 95% CI, 1.26-15.29). Sex and grade 1 to 3 vesicoureteral reflux were not associated with risk of recurrence. Antimicrobial prophylaxis was not associated with decreased risk of recurrent UTI (HR, 1.01; 95% CI, 0.50-2.02), even after adjusting for propensity to receive prophylaxis, but was a risk factor for antibimicrobial resistance among children with recurrent UTI (HR, 7.50; 95% CI, 1.60-35.17).
Conclusion. Among the children in this study, antimicrobial prophylaxis was not associated with decreased risk of recurrent UTI, but was associated with increased risk of resistant infections.
Comments. A 1999 AAP practice guideline recommends an
imaging study for the evaluation of vesicoureteral reflux (VUR)
after a first UTI in an infant or child, and the use of daily antibiotic
prophylaxis in patients with VUR. This study demonstrates that grades 1-3 VUR
are NOT associated with an increased risk of recurrent UTI, and that
antimicrobial prophylaxis does NOT decrease the risk of recurrent UTI – even
in patients with VUR. The most concerning finding was that antibiotic
prophylaxis significantly increased the risk of antimicrobial resistance with
recurrent UTI. I suggest that it is time to change our current practice
regarding UTI prophylaxis, and to update the AAP practice guideline. ABK.
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