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Discontinuation of antibiotic prophylaxis in patients with persistent primary vesicoureteral reflux initially detected during infantile period -outcome analysis and risk factors for febrile urinary tract infection
Kimihiko Moriya, MD, PhD, Takahiko Mitsui, MD, PhD, Takeya Kitta, MD, PhD, Michiko Nakamura, MD, PhD, Katsuya Nonomura, MD, PhD.
Department of Renal and Genitourinary Surgery, Hokkaido University, Sapporo, Japan.
According to the AUA guideline on management of primary vesicoureteral reflux (VUR) in children, conservative management with continuous antibiotic prophylaxis (CAP) is indicated as an initial management for children with primary VUR detected at less than 1 year of age. For patients with persistent VUR on follow-up voiding cystourethrography (VCUG), our strategy in asymptomatic patients is basically active surveillance without CAP under the management of bladder-bowel dysfunction, if necessary. In this study, we retrospectively reviewed our experience of active surveillance in patients with persistent primary VUR initially detected during infantile period and assessed risk factors for febrile urinary tract infection (fUTI).
Among the patients with primary VUR who referred to our hospital at less than 1 year old since 1995, 70 patients (61 boys and 9 girls) who followed without CAP despite persistent VUR on follow-up VCUG were enrolled in this study. Outcome of active surveillance without CAP and risk factors for fUTI were analyzed. Kaplan-Meier curves were generated and log-rank test was indicated for statistical analysis.
Presenting symptoms were fUTI in 62 and abnormality in ultrasonography in 8. Dilated VUR and abnormality on nuclear renal scan at initial evaluation were identified in 57 and in 34, respectively. Mean age when patients stopped CAP was 21 months old (range: 7 to 46). On follow-up VCUG which was performed at the time of stopping CAP, dilated VUR was observed in 49. Mean age at final visit was 6.9 years old (range 1.6-16.5). Nineteen patients had fUTI during active surveillance. Small focal scar was newly developed in 3 of 14 patients who underwent DMSA renal scan after fUTI. Febrile UTI free rate was 70.6% and 51.2% at 5 years and 10 years after discontinuation of CAP. Patients with dilated VUR on follow-up VCUG were significantly at higher risk for fUTI during active surveillance (p=0.03). While abnormality on nuclear renal scan at initial evaluation was tend to be at a higher risk (p=0.06), gender (p=0.55), VUR grade on initial VCUG (p=0.26), presenting symptom (p=0.40), history of breakthrough fUTI before discontinuation of CAP ( p=0.65) , age at stopping CAP (p=0.21) or unilateral/bilateral VUR on initial or follow-up VCUG (p=0.45, 0.64, respectively) was not correlated with incidence of fUTI.
This study revealed that more than half of the patients with persistent VUR were free from fUTI during 10 years active surveillance after discontinuation of CAP and that new scar formation was observed in only the limited number of patients with fUTI. Accordingly, active surveillance seems to be safe option. Those with dilated VUR on follow-up VCUG were significantly at higher risk for febrile UTI under active surveillance for persistent VUR.
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