The Question
Should we treat her prophylactically?
Short-term:
Will this decrease recurrent infections?
Long-term:
Will this decrease renal scarring? Why else would it matter?
■ VUR UTI? ■ VUR Scarring?
Current Treatment Recs
Workup:
Febrile UTI (any age) UTI <5yo UTI x2 in school-age girls UTI in any boy
Imaginotic Prophylaxis
How to Use an Article About Therapy or Prevention
Journal Club Amy K Evans PGY2
August 15, 2006
The Case
Kali is a 14mo female who presents to WRAMC ED with fever to 102. Your stellar Peds Intern suggests obtaining a UA/UCx, which results in the diagnosis of acute pyelonephritis.
No benefit of abx (p=.0291) 7:1 abx:none
Recurrent Pyelo and VUR Degree
6/8 Grade III (cystitis: 46%) 2/8 Grade II (cystitis: 40%) 4/4 pts without VUR
Surgery Surgery
Current Treatment Recs
AUA Pediatric VUR Guidelines Panel (1997)
“The panel recommendations to offer continuous abx prophylaxis…are based on limited scientific evidence. To our knowledge controlled studies comparing the efficacy of continuous prophylaxis and intermittent therapy on health outcomes…have not been performed.”
40% sensitive (VUR)
VCUG
Diagnostic!
DMSA
To treat or not to treat?
AUA Treatment Guidelines
Grade Age (y)
I-II
Any
III-IV 0-5 III-IV 6-10
V
<1
V
1-5
V
1-5
V
6-10
Study Conclusions
Mild/moderate VUR not associated with UTI, pyelonephritis, or scarring
Antibiotic prophylaxis not associated with UTI, pyeloneprhitis, or scarring
Scarring +/-
+/+/-
+/-
+ +/-
Treatment Abx prophy
Abx prophy Unilat: abx Bilat: surgery Abx prophy Unilat: abx Bilat: surgery Surgery Surgery
Follow-Up No consensus Surgery Surgery
No controlled studies? Then what are we basing treatment on?
The State of the Art
Williams et.al. (2001)
Systematic review of RCTs on UTI/abx prophy
Type of Recurrence
Cystitis (no p value)
VUR – 8.6% No VUR – 13.3%
Pyelonephritis (p=.3781)
VUR – 7.1% No VUR – 3.8%
Study Results
Recurrent Pyelo and Antibiotics
Background
Incidence 1-10% Siblings 30-45% (3/4 asymptomatic) Diagnosed via VCUG
UTI workup – 40% (girls); 70% (infants <1yo) Antenatal hydronephrosis – 9% (boys)
Goal: p<.05!
/stats/ask/fishers.asp
Study Results
Recurrence of UTIs
Timing Type
Recurrent Pyelonephritis & Antibiotics Recurrent Pyelonephritis & VUR Degree Renal Scarring
Kali is admitted to Wd51 for 48hrs of IV abx, then, afebrile, discharged to complete po course.
She undergoes renal US and VCUG 3 weeks later, which reveal grade II VUR on the left.
Clinical significance of primary vesicoureteral reflux and urinary antibiotic
prophylaxis after acute pyelonephritis: a multicenter, randomized, controlled study.
Exclusion:
Grade IV-V VUR Anatomic abnormalities Pregnancy
Study Design
Met inclusion criteria VCUG
VUR
Abx
No Abx
No VUR
Abx
No Abx
Pyelo treated: IV abx po for 14-day course Abx: TMP/SMX or nitrofurantoin for 1 year
Background
Vesicoureteral Reflux (VUR) Primary – congenital incompetence of VU valve
(shortened submucosal tunnel) Secondary – multiple anatomic abnormalities
Five trials, 1968-1978
Best 2: 71 patients total, normal anatomy, 92% girls
Garin et.al. (1998)
UTI VUR? no VUR UTI? no
Scars? VUR Scarring? no
■ VUR Pyelo? ■ Degree VUR
Study Results
Analysis of Results
Fisher’s Exact Test
2x2 comparison tables Control vs. variable Smaller sample size Gives p value Does not give CI
The Case
Kali is a 14mo female who presents to WRAMC ED with fever to 102. Your stellar Peds Intern suggests obtaining a UA/UCx, which results in the diagnosis of acute pyelonephritis.
VUR Antibiotics
Study Results
Recurrence of UTI
Overall – 20.1% VUR not significant No abx (p=.9999)
VUR – 22.4% No VUR – 23.3%
Abx (p=0.633)
VUR – 23.6% No VUR – 8.8%
Does antibiotic prophylaxis correlate with UTI/renal scarring?
Study Design
Randomized, controlled, multicenter trial Inclusion:
3mo-18yo Acute pyelonephritis
Kali is admitted to Wd51 for 48hrs of IV abx, then, afebrile, discharged to complete po course.
The Case
Kali is a 14mo female who presents to WRAMC ED with fever to 102. Your stellar Peds Intern suggests obtaining a UA/UCx, which results in the diagnosis of acute pyelonephritis.