Treatment of vesicoureteric reflux: How much benefit?


A new study calls into question the common practice of identifying children with vesicoureteric reflux (VUR) after urinary tract infection (UTI) and then treating the VUR so as to reduce the risk of future UTIs and renal damage. Investigators conducted a meta-analysis of eight trials in a total of almost 900 children from the United States, Europe, and New Zealand, analyzing the incidence of UTI, new or progressive renal damage, renal growth, hypertension, and glomerular filtration rate with different treatments. Seven of the trials compared surgical correction of reflux combined with long-term antibiotics with antibiotic prophylaxis alone. The two treatment groups did not differ significantly in risk of UTI one to two years out or again five years out.

Although febrile UTI declined 60% by five years, there was no accompanying significant reduction in the risk of new or progressive renal damage. In a small, single study (the eighth trial in the meta-analysis) that compared antibiotic prophylaxis with no treatment, the risk of UTI and renal damage was similar in the two groups (Wheeler D et al: Arch Dis Child 2003;88:688).

Commentary: Surprisingly little evidence supports the practice of diagnosing and treating urinary reflux after UTI. At the least, this meta-analysis supports the wisdom of avoiding surgery and instead relying on prophylactic antibiotics alone. Is it appropriate to abandon all treatment (antibiotics and surgery)? Determining that will require more study and more time.

Also of note

A newborn infected with RSV is at low risk of serious bacterial infection. Investigators conducted a retrospective cohort study of infants 8 weeks old or younger with fever who were brought to an emergency department to determine whether the presence of respiratory syncytial virus lowered the risk of serious bacterial infection (SBI). A comparison of 174 infants who had a fever and a positive RSV antigen test with 174 infants who had a fever but a negative RSV test showed that far fewer in the RSV group had SBI than in the control group. The authors question the need for a workup for sepsis, except for urine culture, in an RSV-positive infant (Titus MO et al: Pediatrics 2003;112:282).

DR. BURKE, section editor for Journal Club, is chairman of the department of pediatrics at Saint Agnes Hospital, Baltimore. He is a contributing editor for Contemporary Pediatrics.
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Courtney Nelson, MD
Tina Tan, MD, FAAP, FIDSA, FPIDS, editor in chief, Contemporary Pediatrics, professor of pediatrics, Feinberg School of Medicine, Northwestern University, pediatric infectious diseases attending, Ann & Robert H. Lurie Children's Hospital of Chicago
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