The Best Study of Antibiotic Prophylaxis for Vesicoureteral Reflux

May 21, 2014

The Best Study of Antibiotic Prophylaxis for Vesicoureteral Reflux

  1. Cornelius W. Van Niel, MD

UTI recurred in 15% of children who received prophylaxis versus 27% of placebo recipients.

  1. Cornelius W. Van Niel, MD

Equivocal study results and limited evidence have swung the pendulum away from performing voiding cystourethrograms (VCUGs) and administering antibiotic prophylaxis in children with febrile urinary tract infections (UTIs). Now, the Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) study has been published. Researchers at 19 U.S. centers randomized 607 children (age range, 2–71 months; primarily white, female, and commercially insured) with a first (91%) or second febrile (86%) or symptomatic UTI and vesicoureteral reflux (VUR, grades I–IV) to receive daily prophylaxis with trimethoprim-sulfamethoxazole or placebo. Adherence was good: 77% of children took the study medication 75% of the time.

At 2-year follow-up, febrile/symptomatic UTI recurred in 15% of prophylaxis recipients versus 27% of placebo recipients. At any point in time, prophylaxis reduced the risk for recurrent UTI by 50% overall, and even more in children who had fever with their first UTI (59%) or who were toilet-trained and had bladder/bowel dysfunction (79%). Renal scarring incidence at follow-up was similar in the prophylaxis and placebo groups (12% and 10%). Among 87 children with recurrent UTIs due to Escherichia coli, trimethoprim-sulfamethoxazole resistance was significantly higher in the prophylaxis group (63% vs. 19%).


In this large, well-conducted randomized trial, eight children with recent UTI and VUR needed to receive prophylaxis to prevent one recurrent UTI. However, prophylaxis did not prevent renal scarring during 2-year follow-up. As editorialists note, whether preventing recurrent UTIs is worth risking antimicrobial resistance and potential microbiome alterations is an open question. The data provide us with strong evidence on which to base clinical decisions for individual patients.

Editor Disclosures at Time of Publication

  • Disclosures for Cornelius W. Van Niel, MD at time of publication Equity Covidien; Express Scripts; Johnson & Johnson; Merck


Reader Comments (2)

JOSE MUNIZ Physician, Allergy/Immunology, private office


Brian Mahood Other Healthcare Professional, Pulmonary Medicine, Retired physician from Waikato Hospital, Hamilton, New Zealand

It is good that a proper study of adequate size has been undertaken because it reduces the uncertainty relating to on going management from both the treating physician and the parents.

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