Girls and abnormal findings on DMSA scintigraphy are risk factors for febrile urinary tract infection after stopping continuous prophylactic antibiotics in patients with primary vesicoureteral reflux, -Single center analysis-.
Michiko Nakamura, MD, PhD, Kimihiko Moriya, MD, PhD, Yoko Nishimura, MD, Masafumi Kon, MD, PhD, Takeya Kitta, MD, PhD, Nobuo Shinohara, MD, PhD.
Department of Renal and Genitourinary Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan.
BACKGROUND: Conservative management with continuous antibiotic prophylaxis (CAP) is indicated as initial treatment for children with primary vesicoureteral reflux (VUR). However, there is no consensus about management of patients with persistent VUR who have no recurrent febrile urinary tract infection (fUTI) under CAP. Our strategy in such patients is basically active surveillance, which means that patients are followed without CAP. We retrospectively investigated the incidence of and risk factors for fUTI in patients with persistent VUR after discontinuation of CAP. METHODS: Among patients with primary VUR under 10 years of age at presentation who were born between 2001 and 2016, those who had persistent VUR despite conservative management with CAP and who were subsequently followed after discontinuation of CAP were included. VUR was classified into 5 grade according to the International Reflux Study in Children, and high grade VUR was defined as grade 4 and 5. We analysed the incidence of and risk factors for fUTI after stopping CAP. Kaplan-Meier curve was used for the evaluation of fUTI-free rate. Statistical analysis was performed by Cox's proportional hazard regression model and log-rank test. P <0.05 was considered significant. Results: A total of 144 patients met the inclusion criteria. The number of boys or girls was 99 or 45, respectively. Median age at first presentation was 8.8 months old. Presenting symptom was mainly fUTI (130 pts (90%)). High grade VUR was detected on initial evaluation in 68 pts (47%) and at the time of stopping CAP in 48 pts (33%). Among 139 pts who underwent DMSA scintigraphy after presentation, 78 patients (56%) had abnormal findings. Median follow-up under CAP was 16.5 months. Median age at stopping CAP was 25 months old and median follow-up after stopping CAP was 5.1 years. During follow-up, 34 pts had fUTI. Five-year fUTI-free rate after discontinuation of CAP was 70.5%. On univariate analysis, significantly higher rate of fUTI after discontinuation of CAP was identified in girls (p=0.0026), in patients with abnormal findings of DMSA scintigraphy (p=0.0414) or >1 year of age at presentation (p=0.0475). On multivariate analyses, girls (p=0.0012) and abnormal findings on DMSA scintigraphy (p=0.0029) were significant risk factors for fUTI. Five-year fUTI-free rate was 79.3% in boys and 51.7% in girls (p=0.0014), and 61.4 % with and 80.6 % without abnormal findings on DMSA scintigraphy (p=0.0454). In 12 girls with abnormal findings on DMSA scintigraphy, 5-year fUTI-free rate was 16.7%. There was no significant difference in the incidence of fUTI based on VUR grade at presentation and follow up VCUG, age at first visit or stopping CAP, the presences of constipation, phimosis, bilateral VUR, or the type or duration of CAP. CONCLUSIONS: This study revealed that 70% patients with persistent VUR were free of fUTI for 5 years after stopping CAP. Girl and abnormal findings on DMSA scintigraphy were risk factors for fUTI after stopping CAP. Accordingly, longer administration of CAP or prophylactic surgery before recurrent fUTI should be indicated in patients with these risk factors.
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