Antibiotic prophylaxis in vesicoureteral reflux: between evidence and clinical practice

Vesicoureteral reflux is one of the most common urological conditions in paediatrics. Depending on the clinical presentation, the number of recurrent urinary tract infections, the grade of vesicoureteral reflux, and the presence of other comorbidities, treatment options include surveillance, continuous antibiotic prophylaxis, and endoscopic or surgical intervention.Continuous antibiotic prophylaxis remains controversial, as some studies have demonstrated a benefit in preventing recurrent urinary tract infections, whereas others have not, particularly with regard to the prevention of renal scarring. In addition, continuous antibiotic prophylaxis is associated with increased antimicrobial resistance and alterations in the gut microbiota.Recent nephrological and urological guidelines indicate that continuous antibiotic prophylaxis is not routinely required in children with low-grade vesicoureteral reflux and is mainly recommended for those with high-grade vesicoureteral reflux, bladder and bowel dysfunction, and/or recurrent urinary tract infections. The guidelines generally support continuing prophylaxis until bladder and bowel dysfunction has resolved and the child has remained free of urinary tract infections for an extended period. They are also broadly consistent regarding the choice and dosage of antibiotics. Our clinical practice recommendations provide an additional perspective on the management of vesicoureteral reflux in children.This review focuses on the role of continuous antibiotic prophylaxis in children from both nephrological and urological perspectives, including its advantages and disadvantages, alternative treatment strategies, and our own perspective based on long-term clinical observation and experience.