UROLOGICAL SURVEY   ( Download pdf )

 

PEDIATRIC UROLOGY

Is Antibiotic Prophylaxis Necessary in Infants with Obstructive Hydronephrosis?
Song SH, Lee SB, Park YS, Kim KS.
Department of Urology, CHA General Hospital, College of Medicine, Pochon CHA University, Seoul, Korea.
J Urol. 2007;177:1098-101; discussion 1101

  • Purpose: We investigated the relationship between the level of obstruction of the upper urinary tract and the risk and onset of urinary tract infection in infants with severe obstructive hydronephrosis to determine the need for antibiotic prophylaxis.
  • Materials and Methods: A total of 105 patients were prenatally diagnosed with severe hydronephrosis (Society for Fetal Urology grade III or IV) due to upper urinary tract obstruction between 1994 and 2004. Of these patients 75 had ureteropelvic junction obstruction and 30 had lower ureteral obstruction. We retrospectively evaluated the clinical course and incidence of urinary tract infection during the first 12 months postnatally without antibiotic prophylaxis.
  • Results: The incidence of overall urinary tract infection during followup was 36.2% (38 of 105 patients), and it demonstrated a higher trend with lower ureteral obstruction than with ureteropelvic junction obstruction (50% vs 30.7%, p=0.063). Most cases of urinary tract infection (92.8%) occurred before age 6 months, with a mean age at onset of 2.6 months. Of 105 patients 77 (73.3%) underwent corrective surgery at a mean age of 3.8 months. The incidence of urinary tract infection before surgical correction was 33.8% at a mean age of 2.1 months. The incidence of urinary tract infection in surgical cases was significantly higher with lower ureteral obstruction than with ureteropelvic junction obstruction (54.2% vs 24.5%, p=0.011).
  • Conclusions: Urinary tract infection in infants with severe obstructive hydronephrosis has a high incidence, occurs before age 6 months and is more common with lower ureteral obstruction than with ureteropelvic junction obstruction. These findings indicate that infants with severe hydronephrosis due to obstruction of the upper urinary tract should receive antibiotic prophylaxis.

  • Editorial Comment
    105 congenital hydronephroses due to upper urinary tract blockages were evaluated during a ten year period. 99 were unilateral and six were bilateral. Forty-seven had SFU Grade III hydronephrosis and 58 had Grade IV. None of the 82 males were circumcised. All patients were followed without prophylactic antibiotics. Seventy-five had ureteropelvic junction obstruction and 30 patients had lower urinary tract obstruction, 18 of which had ureterovesical junction obstruction. There were 10 ureteroceles and 2 ectopic ureters. Surgery was performed if a UTI occurred, or when there was an increased anterior and posterior pelvis diameter or an increased drainage time with worsening obstructive curve or decreasing relative renal function less than 40.
    The overall incidence of UTI during follow up was 36.2% (38/105 patients), 50% of the lower urinary tract obstructions and 30.7% of the upper urinary tract obstructions had a UTI. 92.8% of these infections occur before six months of age with a mean age of onset of 2.6 months. Of the 105 patients, 77 underwent corrective surgery at a mean age of 3.8 months. Their data suggested that there is a higher risk of infection for obstructions near the bladder and they recommended prophylactic antibiotics for infants with SFU Grade III and IV obstruction during observation periods.
    This is a higher rate of infection than is sometimes reported and a much higher surgery rate at earlier ages than is usually recommended. For ureteropelvic junction obstructions, half of the patients will resolve spontaneously by waiting 18 months or more. It is surprising that their patients either had infections or other indications for surgery by a mean age of 3.8 months. This probably indicates that this is a highly selective group of patients but still suggests that prophylactic antibiotics may be required.

Dr. Brent W. Snow
University of Utah Health Sci Ctr
Division of Urology
Salt Lake City, Utah, USA
E-mail: brent.snow@hsc.utah.edu