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Recurrent Urinary Tract Infections in Children
Risk Factors and Association With Prophylactic Antimicrobials
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JAMA. 2007;298:179-186
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Patrick H. Conway, MD, MSc; Avital Cnaan, PhD; Theoklis
Zaoutis, MD, MSCE; Brandon V. Henry, BS; Robert W. Grundmeier, MD; Ron Keren,
MD, MPH
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Context
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The evidence regarding risk factors for recurrent urinary
tract infection (UTI) and the risks and benefits of antimicrobial
prophylaxis in children is scant. |
Objectives
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To identify risk factors for recurrent UTI in a pediatric primary care
cohort, to determine the association between antimicrobial prophylaxis and
recurrent UTI, and to identify the risk factors for resistance among
recurrent UTIs.
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Design, Patients, and Setting
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From a network of 27 primary care pediatric practices in urban, suburban,
and semirural areas spanning 3 states, a cohort of children aged 6 years or
younger who were diagnosed with first UTI between July 1, 2001, and May 31,
2006, was assembled. Time-to-event analysis was used to determine risk
factors for recurrent UTI and the association between antimicrobial
prophylaxis and recurrent UTI, and a nested case-control study was performed
among children with recurrent UTI to identify risk factors for resistant
infections.
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Main Outcome Measures
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Time to recurrent UTI and antimicrobial resistance of recurrent UTI
pathogens.
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Results
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Among 74 974 children in the network, 611 (0.007 per person-year) had a
first UTI and 83 (0.12 per person-year after first UTI) had a recurrent UTI.
In multivariable Cox time-to-event models, factors associated with increased
risk of recurrent UTI included white race (0.17 per person-year; hazard
ratio [HR], 1.97; 95% confidence interval [CI], 1.22-3.16), age 3 to 4 years
(0.22 per person-year; HR, 2.75; 95% CI, 1.37-5.51), age 4 to 5 years (0.19
per person-year; HR, 2.47; 95% CI, 1.19-5.12), and grade 4 to 5
vesicoureteral reflux (0.60 per person-year; HR, 4.38; 95% CI, 1.26-15.29).
Sex and grade 1 to 3 vesicoureteral reflux were not associated with risk of
recurrence. Antimicrobial prophylaxis was not associated with decreased risk
of recurrent UTI (HR, 1.01; 95% CI, 0.50-2.02), even after adjusting for
propensity to receive prophylaxis, but was a risk factor for antibimicrobial
resistance among children with recurrent UTI (HR, 7.50; 95% CI, 1.60-35.17).
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Conclusion
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Among the children in this study, antimicrobial prophylaxis was not
associated with decreased risk of recurrent UTI, but was associated with
increased risk of resistant infections.
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Author Affiliations:
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Robert Wood Johnson Foundation Clinical Scholars Program (Dr Conway),
Leonard Davis Institute of Health Economics (Drs Conway, Zaoutis, and Keren),
Center for Clinical Epidemiology and Biostatistics (Drs Conway, Cnaan,
Zaoutis, and Keren), and School of Medicine (Mr Henry), University of
Pennsylvania, Philadelphia; Division of General Pediatrics (Drs Conway,
Zaoutis, and Keren), Division of Biostatistics and Epidemiology (Dr Cnaan),
and Center for Biomedical Informatics (Dr Grundmeier), Children's Hospital
of Philadelphia; and Center for Health Care Quality and Division of General
Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
(Dr Conway).
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