RIVUR trial offers confirmatory evidence for a small but real benefit of antibiotics for UTI prevention in children

Commentary on; RIVUR Trial Investigators, Hoberman A, Greenfield SP, Mattoo TK, et al. Antimicrobial prophylaxis for children with vesicoureteral reflux. N Engl J Med 2014;370:2367–76.
Context
Urinary tract infections (UTIs) are common in children and can cause considerable morbidity; furthermore, UTIs recur in 10–20% of patients.1–3 Some literature claims there are serious adverse long-term consequences of UTIs, such as hypertension and end-stage kidney disease, but evidence is sparse and lacks denominators.4 ,5 Numerous trials of low-dose antibiotics for recurrent UTIs have been published and six systematic reviews have synthesised these data. Early trials were small and poorly designed and focussed on select groups of children, making them relatively uninformative for clinical guidance. The power and statistical precision of better-designed later trials was limited by small study size. In 2009 the largest trial then published—placebo-controlled and assessing a broad range of children—demonstrated a small but significant reduction in symptomatic UTIs with preventive antibiotic use over 1 year. Antibiotics were associated with increased antimicrobial resistance.6 The large and similarly designed RIVUR trial recently confirmed these findings.