A Cochrane review included 20 studies with a total of 2 324 children. Ten compared correction of vesicoureteric reflux (VUR) (by surgery or endoscope) plus antibiotics for 1–24 months with antibiotics alone, eight compared antibiotics with no treatment or placebo and two compared different materials for endoscopic correction of VUR. Long-term low-dose antibiotic prophylaxis compared to no treatment/placebo did not significantly reduce repeat symptomatic urinary tract infections (UTI) (RR 0.68, 95% CI 0.39 to 1.17; 5 studies, n=846) or febrile UTI (RR 0.77, 95% CI 0.47 to 1.24; 6 studies, n=946) at two years. There was considerable heterogeneity in the analyses and only one study was adequately blinded. At one to three years, antibiotic prophylaxis reduced the risk of new or progressive renal damage on dimercaptosuccinic acid (DMSA) scan (RR 0.35, 95% CI 0.15 to 0.80; 3 studies, n=446). Assuming a baseline risk of 8%, 33 children would need prophylaxis to prevent one extra child developing a new or progressive renal scar over the course of two to three years. Side effects were infrequent when reported, but antibiotics increased the likelihood of bacterial drug resistance threefold (RR 2.94, 95% CI 1.39 to 6.25; 132 UTIs).
When long-term antibiotic prophylaxis was compared with surgical or endoscopic correction of VUR plus antibiotics for one to 24 months (10 studies, n=1 141), the risk of symptomatic UTI was not significantly different at any time point. Combined surgical and antibiotic treatment caused a 57% reduction in febrile UTI by five years (RR 0.43, 95% CI 0.27 to 0.70; 2 studies, n=449) but did not decrease the risk of new or progressive renal damage at any time point. Postoperative obstruction was seen in 0% and 7% of children in two surgical studies and 0% in one endoscopic study.
Comment: The quality of evidence is downgraded by study quality (inadequate or unclear allocation concealment and lack of blinding) and by imprecise results (few patients and wide confidence intervals ).