Prophylactic Antibiotics for the Treatment of Vesicoureteral Reflux
The American Urology Association guidelines (1997) recommend that children with Vesicoureteral Reflux grades I-IV should be treated with daily antibiotic therapy (also known as prophylactic antibiotics). Prophylactic antibiotics have been used as a first step in treating Vesicoureteral Reflux since the 1960s. The idea is based on the premise that a small daily dose of antibiotics will kill any bacteria in the urine which will keep the bladder sterile, and would therefore be beneficial in preventing UTI and renal scarring. If UTI can be prevented, the kidneys will be protected, and the child can have time for the reflux to resolve without further treatment (most common in the lower grades of reflux).
Since that time, the use of antibiotics has been widely debated, however most doctors still use antibiotics as their first step in treating reflux.
There are only a few types of antibiotics that can be used for prophylaxis in children with VUR. The most common types used are trimethoprim sulfamethoxazole (Bactrim), nitrofurantoin (Furadantin) and penicillin derivatives of amoxicillin. These antibiotics are used because their active form is excreted in urine which in theory should keep the urine sterile. Trimethoprim sulfamethoxazole (Bactrim) is the most commonly used prophylaxis for the treatment of VUR. The only antibiotic safe for use in children 3 months or younger is the penicillin derivatives of amoxicillin. For more information on the types of abx used for treatment click here.
There are risks and problems associated with prolonged daily use of antibiotics in treating VUR. These include compliance, side effects, resistant bacteria and effectiveness of the antibiotic. It is generally accepted that children with lower grades of reflux and no other complications (such as hydronephrosis, significant renal scarring, etc) can safely be taken off of antibiotics at the age of 5. Studies have shown that by the age of 5, the chances of renal scarring are significantly reduced.
There has been a lot of debate about the safety and effectiveness of antibiotics in recent years. For the purpose of this article, we have given information solely based on the AUA recommendations that antibiotics should be given as a first step in treating reflux. For more information on antibiotics and why some believe they are ineffective, and possibly dangerous, please read our article “Antibiotics – What’s the Big Debate?“.
Antibiotics – What’s the Big Debate?
In recent years, there has been an ongoing debate about the use of prophylactic antibiotics for the treatment of VUR. Is it effective? Is it safe? What are there side effects? Are the dangers worth the risk? There is a lot of information out there. Some of it good, some of it not so much so. My first recommendation? Do your research, so that you can make an informed decision. Know which antibiotic will be given, the dosage and the side effects. Some kids do great with antibiotics, and experience very few side effects. Other children don’t do well at all. As a parent, our job is to make the best decision we can for our children, and that decision will be different for everyone.
I’ll start this article off by saying that I am (personally) not a big fan of daily antibiotics. That being said, I also realize that they are still the best option for many children with VUR. No one should ever discontinue antibiotics without first discussing it with their doctor, and you should speak openly with your doctor about any concerns you may have about daily antibiotics. So here we go…
What ‘s the big debate?
The biggest question of course is whether or not daily antibiotics are effective in preventing urinary tract infection and renal scarring. Unfortunately there is still no clear cut answer. There have not been enough long term comprehensive studies to provide definitive answers to this question, but many new studies are ongoing, such as the RIVUR project. For years doctors have been prescribing low dose antibiotics to children with VUR with the belief that antibiotics help in the prevention of UTI. The idea is that the antibiotics will keep the urine sterile which will prevent/reduce the number of breakthrough UTI’s.
Many recent studies are beginning to show that antibiotics may not be as effective in preventing UTI or renal scarring as once believed. For example, this study concludes that “Furthermore, their data do not support a role for antibiotic prophylaxis to prevent recurrence of infection or the development of renal scars (in fact, in this study, prophylaxis increased the chance of developing APN (kidney infecrtion)!).” The most interesting part of the study is that in the 8 patients with VUR that had recurrent kidney infections (APN), 7 of them were on prophylactic antibiotics. Only one child from the group not being treated had recurrent kidney infection. Even more interesting to me, is that all 7 of the children on antibiotics developed bacteria that was resistant to the antibiotic that they were given as a prophylactic. That brings up major concerns about resistance issues in prophylactic antibiotics. While this study produced interesting results, it was a small study in which only 236 patients were enrolled, and larger studies with more specific guidelines are needed. That being said, the conclusions can’t be just be swept aside either.
Another recent study here shows that the use of probiotics may be just as effective as using prophylactic antibiotics. While this sounds extremely promising, one must also keep in mind that the effectiveness of antibiotics is being called into question. There are also studies that suggest early intervention with Deflux injection may be more effective and safer than long term antibiotics. There are more comprehensive studies being conducted currently to verify the findings of this research.
Another question that surfaces when talking about antibiotics is whether or not antibiotics are safe for long term use. While most doctors will tell you that antibiotic use at this low dose is harmless, there are some risks associated with the prolonged use of antibiotics. One of the biggest concerns of long term use is the risk of resistant bacteria. Bacteria can become resistant to antibiotics, causing infections that are harder to kill off, and harder to treat. Many times these bacterial infections will require stronger IV antibiotics, and can lead to more dangerous infections that have fewer treatment options. There is also the fear of a superbug that may have very limited treatment options. Other problems include an increase in problems later in life such as allergies and asthma.
You should also be aware of the drugs side effects. The side effects of different antibiotics will vary in different children. Some of the more general side effects may include, gut issues such as diarrhea or nausea and chronic yeast infection. The problem with antibiotics is that they not only kill the harmful bacteria in the body, but also kill the beneficial bacteria found in the gut. This imbalance can cause uncomfortable gut issues, as well as yeast overgrowth.
So, are the benefits of antibiotics worth the risks? This is such a personal decision, and it’s a hard question to answer. I know some parents who think that antibiotics are wonderful and feel that they have really helped their children remain healthy. Many kids have no adverse side effects, and no recurrent infections while on antibiotics. While most children do fine on antibiotics, that is not always the case and for some children they may not be a good solution. You should always talk to your doctor if you have concerns about the use of antibiotics.