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Recurrent Urinary Tract Infections in ChildrenRisk Factors and Association With Prophylactic Antimicrobials
Patrick H. Conway, MD, MSc;
Avital Cnaan, PhD;
Theoklis Zaoutis, MD, MSCE;
Brandon V. Henry, BS;
Robert W. Grundmeier, MD;
Ron Keren, MD, MPH
JAMA. 2007;298:179-186.
Context The evidence regarding risk factors for recurrent urinary tract infection (UTI) and the risks and benefits of antimicrobial prophylaxis in children is scant.
Objectives 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.
Design, Patients, and Setting 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.
Main Outcome Measures Time to recurrent UTI and antimicrobial resistance of recurrent UTI pathogens.
Results 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).
Conclusion 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.
Author Affiliations: 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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