Is continuous antibiotic prophylaxis in children with vesicoureteral reflux really ineffective in preventing pyelonephri
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LETTER TO THE EDITORS
Is continuous antibiotic prophylaxis in children with vesicoureteral reflux really ineffective in preventing pyelonephritis? Shuichiro Fujinaga & Kazunari Kaneko & Yoshiyuki Ohtomo & Daishi Hirano & Naoto Nishizaki & Tomonosuke Someya & Yoshikazu Ohtsuka & Toshiaki Shimizu
Received: 12 February 2009 / Revised: 17 February 2009 / Accepted: 18 February 2009 / Published online: 14 March 2009 # IPNA 2009
Sirs, Although long-term antibiotic prophylaxis (AP) has been used for patients with vesicoureteral reflux (VUR) in order to prevent urinary tract infections for many years, recent randomized controlled trials (RCTs) revealed that AP with sulfametoxazole/trimethoprim (SMX/TMP) or nitrofurantoin was ineffective in reducing the rate of recurrence of pyelonephritis in children with low grade VUR and was associated with an increased risk of resistant infections [1– 3]. On the other hand, because of the increase in organisms resistant to SMX/TMP, conventional AP using low-dose cephalosporins, such as cefaclor (CCL), has been favored by many pediatric nephrologists and urologists in Japan for more than 10 years. Although we previously reported the efficacy and safety of the strategies of AP using low doses of CCL for children with VUR in this journal, since then there has been a paucity of evidence for the agent [4]. To investigate whether long-term use of CCL could effectively reduce the risk of recurrent pyelonephritis in comparison S. Fujinaga (*) : D. Hirano : N. Nishizaki Division of Nephrology, Saitama Children’s Medical Center, 2100 Magome, Iwatsuki-ku, Saitama City, Saitama 339 8551, Japan e-mail: [email protected] K. Kaneko Department of Pediatrics, Kansai Medical University, Moriguchi City, Osaka, Japan Y. Ohtomo Department of Pediatrics, Juntendo Nerima Hospital, Nerima-ku, Tokyo, Japan T. Someya : Y. Ohtsuka : T. Shimizu Department of Pediatrics, Juntendo University School of Medicine, Bunkyo-ku, Tokyo, Japan
with SMX/TMP, we therefore reviewed retrospective data from children with VUR, including grade IV or V, in our hospital. Two hundred and forty-two children (168 male, 74 female) with VUR who had been diagnosed by voiding cystourethrography after acute pyelonephritis and had received AP (CCL or SMX/TMP) for more than 6 months in Saitama Children’s Medical Center from April 1994 to December 2008 were enrolled in this study. The VUR grade was based on the maximum grade on either side of the urinary collecting system (grade I, 7; II, 41; III, 64; IV, 82; V, 48). Of the 242 patients, 184 (76%) had received AP with CCL (5–10 mg/kg per day), while the remaining 58 (24%) had received SMX/TMP (5–10 mg/kg per day SMX and 1–2 mg/kg per day TMP). The choice of antibiotics and the duration of AP depended on the decisions of different physicians. The children’s ages at the first episode of acute pyelonephritis varied from 0.5 months to 127 months (median 4 months). The mean duration of treatment for patients who had received AP was 21±13.5 months. Forty patients (17%) developed breakthrough in
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