Vesicoureteral Reflux: The Role of Antibiotic Prophylaxis

Urinary tract infection (UTI) is now the most common serious bacterial infection that occurs in infancy and early childhood in the United States.1 The prominence of UTI is a result, in great part, of the dramatic reduction of the previously common manifestations of infection caused by Haemophilus influenzae type b and Streptococcus pneumoniae due to the introduction and near-universal dissemination of effective conjugate vaccines in childhood. The current standard of care in the management of UTI (especially for young infants and children) includes the performance of imaging procedures.2 Although some controversy has surrounded the selection of imaging procedures, the potential menu of choices includes renal ultrasound, voiding cystourethrogram (VCUG), and renal scintigram. Formerly, the intravenous pyelogram was included among the choices but has been replaced, for most intents and purposes, by renal ultrasound. Renal ultrasound is used to assess the gross anatomy of the urinary tract and thereby detect obstructive uropathies. It is a noninvasive test that adequately describes renal size, detects dilatation and duplication of the collecting system, and gross anatomic abnormalities such as a horseshoe kidney.2 Although ultrasounds have become standard in the evaluation of children with UTI, it is worth rethinking their contribution to management. In an era when ultrasounds are performed routinely during pregnancy (and sometimes on multiple occasions), they may be superfluous in the evaluation of a child with UTI.3 Most children with congenital obstruction of the urinary tract are diagnosed in utero. If an ultrasound was performed in the latter part of gestation (beyond 30–32 weeks of gestation) at an experienced institution and found to be normal, repeating it when a young child presents with UTI has a negligible impact on management. In a recent study that evaluated intravenous versus oral treatment of 306 children between the ages of 1 … Address correspondence to Ellen R. Wald, MD, Department of Pediatrics, Box 4108, University of Wisconsin Children's Hospital, 600 Highland Ave, Madison, WI 53792. E-mail: erwald{at}wisc.edu