Treatment with Two Antibiotics Dramatically Reduces Risk of Urinary Tract Infections in Children
Long-term use of a drug combination can reduce the risk of recurrent urinary tract infection by up to 80 percent in children with vesicoureteral reflux (VUR). In children with this condition, developmental abnormalities in one or both ureters—the tubes connecting the kidneys to the bladder—allow urine to flow back from the bladder into the ureters, and sometimes into the kidneys. This can lead to recurrent urinary tract infections (UTIs) and, in severe cases, scarring of the kidneys.
For decades, doctors have treated children who have VUR with a small daily dose of the antibiotics trimethoprim and sulfamethoxazole (TMP/SMZ), often for years, with the hope of preventing recurrent UTIs and kidney damage. Although this approach seemed logical, there was no conclusive evidence that it provided long-term benefits. The Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) study examined the use of this drug combination in a well-defined population of over 600 young children with VUR whose ages ranged from 2 months to 6 years over a 2-year period. RIVUR found that the risk of recurrent infection was reduced by 50 percent in children with VUR who received TMP/SMZ. Children with VUR and bladder and bowel dysfunction saw an even greater reduction, up to an 80 percent lower risk of recurrent infections. Children with this condition are more likely to have recurrent urinary infections, which can increase their risk of kidney scarring and the potential for kidney failure.
While TMP/SMZ significantly reduced the incidence of recurrent UTIs during the trial, the number of children who developed kidney scarring did not decrease in the group receiving the antibiotics. The researchers suggest this may be due to parents’ heightened vigilance for UTI symptoms and early treatment in the trial and because most of the children were enrolled after their first infection rather than after multiple infections, when more scarring might occur.
Further analysis of data from the RIVUR trial may provide insight into other factors that could reduce susceptibility to recurrent UTIs and kidney scarring. For now, though, the RIVUR study has demonstrated that treatment with TMP/SMZ offers the possibility of fewer infections for children with VUR, which may provide an opportunity for many of them to outgrow reflux as their bodies develop and mature.
The RIVUR Trial Investigators. Antimicrobial prophylaxis for children with vesicoureteral reflux. N Engl J Med 370: 2367-2376, 2014.