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Evidence summaries

Interventions for Primary Vesicoureteric Reflux

Long-term low-dose antibiotic treatment may make little or no difference to the risk of repeat symptomatic and febrile urinary tract infections in children with vesocoureteric reflux (VUR) compared with no treatment. The added benefit of surgical or endoscopic correction of VUR over antibiotic treatment alone remains unclear. Level of evidence: "C"

The quality of evidence is downgraded by study limitations (lackf of/unclear allocation concealment and blinding), and by inconsistency (unexplained variability in results).

Summary

A Cochrane review [Abstract] 1 included 34 studies with a total of 4 001 children with vesicoureteric reflux (VUR). Interventions included long-term low-dose antibiotics, surgical reimplantation of ureters, endoscopic injection treatment, probiotics, cranberry products, circumcision, and oxybutynin, and were used alone and in combinations.

Long-term low-dose antibiotic prophylaxis compared to no treatment/placebo did not significantly reduce repeat symptomatic urinary tract infections (UTI) (RR 0.77, 95% CI 0.54 to 1.09; 9 studies, n=1 667; statistical heterogeneity I2 =59%) or febrile UTI (RR 0.83, 95% CI 0.56 to 1.21; 9 studies, n=1 667; I2 =51%) at 1 to 2 years, although the pooled estimates favoured antibiotic treatment. At 1 to 3 years, antibiotic prophylaxis did not reduce the risk of new or progressive renal damage on dimercaptosuccinic acid (DMSA) scan (RR 0.73, 95% CI 0.33 to 1.61; 8 studies, n=1 503). Adverse events were reported in 4 studies (n=1 056) and no difference between groups was observed (RR 0.94, 95% CI 0.81 to 1.08), but antibiotics increased the likelihood of bacterial drug resistance threefold (RR 2.97, 95% CI 1.54 to 5.74; 187 UTIs).

Surgical reimplantation of ureters plus antibiotic treatment compared to antibiotics alone reduced the risk of repeat febrile UTI by 57% (RR 0.43, 95% CI 0.27 to 0.70; 2 studies, n=429). There was little or no difference in the risk of new kidney defects detected using intravenous pyelogram at 4 to 5 years (RR 1.09, 95% CI 0.79 to 1.49; 4 studies, n=572). There was no difference in the risk of febrile UTI when endoscopic injection was compared to antibiotics alone (RR 0.74, 95% CI 0.31 to 1.78; 3 studies, n=254; I2 =58%).

There was no difference between probiotic treatment and antibiotics in risk of repeat symptomatic UTI (RR 0.82 95% CI 0.56 to 1.21; 2 studies, n=248).

    References

    • Williams G, Hodson EM, Craig JC. Interventions for primary vesicoureteric reflux. Cochrane Database Syst Rev 2019;2():CD001532. [PubMed]. .

Primary/Secondary Keywords