the aim of this review was to systematically examine the available evidence for the effectiveness of prophylactic antibiotics in cases of vesicoureteric reflux ( vur ) .
we searched the relevant data on medical management of vur and the date of last search was june 2008 .
the search included both randomized controlled trials as well as the nonrandomized trials and the data sources were ; medline , online peer reviewed journals , cochrane database and abstracts from conference proceedings .
besides being small in number many of these studies were of poor - quality and poorly designed eventually failing in giving a reliable answer in this regard .
few of the studies suggest that the children with low grade vur might do well even without antibiotic prophylaxis .
in the absence of properly designed , randomized controlled trials and long - term follow - up the question of antibiotic prophylaxis in cases of vur remains unanswered in large part of it . whether to give prophylactic antibiotics or not would ultimately need a shared decision - making involving both the treating physician and the parents assessing both the risks and the benefits .
in 1997 , the american urological association ( aua ) pediatric vesicoureteral reflux guidelines panel recommended an antibiotic prophylaxis as an appropriate or a reasonable initial therapy for all children up to 5 years of age who have primary reflux grade i - iv .
the main concerns were that the infection and the reflux , even if it is low grade , can lead to renal injury.[26 ] recently , this concept of presumed benefit of antibiotic prophylaxis has been challenged and its efficacy been questioned.[279 ] further , the matter has been debated on the ground that ; it not only incurs cost but also carries the inherent risk of adverse effect of the antibiotics .
the aim of this review was to systematically examine the available evidence of the effectiveness of prophylactic antibiotic .
after the first symptomatic urinary tract infection ( uti ) , nearly 6 - 10% of the children develop renal scarring .
the renal scars may even develop in 10 - 15% of the patients with low - grade reflux .
the main concern remains the risk of development of chronic kidney disease ( ckd ) and hypertension ( ht ) in adulthood in many of these children , which have been reported up to 10 and 23% , respectively .
this association between uti , renal scarring , and ht has given birth to the concept of prophylactic antibiotics and surveillance in cases of vesicoureteric reflux ( vur).[35 ] saux et al .
( 2000 ) in a meta - analysis of six randomized studies reported a higher rate of infection in control group as compared to the children who received antibiotic prophylaxis .
the rate of infections for patients with normal urinary tracts ranged from 0 to 4.0 per 10 patient - years in the treatment groups ( i.e. on antibiotic prophylaxis ) and from 4.0 to 16.7 in the control groups . in another recent meta - analysis ,
( 2006 ) compared the efficacy of antibiotics with placebo / no treatment in 406 children .
the duration of antibiotic prophylaxis treatment in these studies varied from 10 weeks to 12 months .
when compared to placebo or no treatment , antibiotics reduced the risk of repeat positive urine culture and no side effects were reported .
( 2002 ) reported the outcome of 66 children considered at risk for uti during the period of suppressive antibiotics .
the follow - up period was 3.7  2.2 years ( range 0.92 - 9.83 years ) .
it was inferred that most of the children with low - grade vur did well . however , there was an increased risk of infection among those with voiding dysfunction and vur of grade 3 or greater .
these observations highlight that the higher grades are at definitive risk of developing uti or febrile uti and need to be addressed differently as compared to lower grades .
( 2006 ) , the occult vur was detected by positioned instillation of contrast and not by the conventional voiding cystourethrogram ( vcu ) after febrile uti .
the overall incidence of febrile uti was reported to be reduced significantly from 0.16 per patient per month to 0.008 after the antibiotic prophylaxis .
contrary to this , some of the studies , although nonrandomized , have shown the incidence of uti between 20 and 30% in spite of prophylactic antibiotics .
moreover , some of the randomized studies have also raised doubts regarding the preventive role of prophylactic antibiotics.[69 ] kesler et al .
( 2008 ) in a multicenter , prospective , randomized study of the children under 3 years of age with grade i - iii did not find any significant difference in the recurrence of utis as well as febrile utis ( p = 0.2 ) in both the groups .
however , the incidence of uti was significantly higher in boys with grade iii vur ( p = 0.042 ) .
( 2006 ) in another multicenter , randomized , controlled study of children with mild - to - moderate vur reported similar rate of utis , pyelonephritis , and new scars in both the groups ( 23 vs 22 ) after one - year follow - up .
wheeler et al . ( 2004 ) performed a meta - analysis of 10 randomized controlled trials ( 964 children ) to evaluate whether any intervention for vur is better than no treatment .
they also highlighted that no significant differences in risk for uti or renal damage were found between antibiotic prophylaxis and no treatment in one small study .
interestingly , in some of these studies analysed , the authors tried to document that the antibiotic prophylaxis may not be useful in low - grade vur ; however , one should not undermine the malicious sequealae of vur that may be associated with even the first uti and any grade of reflux .
( 2004 ) reported that after an episode of uti , 51% of the children had an abnormal dimercapto - succinic acid scintigraphy ( dmsa ) scan and 46% with a positive dmsa scan had no evidence of vur on vcug .
there was a significant association between grade iii or higher vur and dmsa positive renal lesions .
moreover , one should be careful in interpreting these studies , both for and against , due to low quality , duration of antibiotic prophylaxis treatment not being uniform , short follow - up besides many not being double - blind , and lacking a placebo arm . currently , the national institute of diabetes and digestive and kidney ( niddk ) is running a prospectively randomized trial to study the long - term effect of antibiotic prophylaxis on vur .
once the data are mature we may be able to answer many of the unsolved mysteries associated with vur .
despite the suggestions made through some of the recent studies that the children with low - grade vur might do well even without antibiotic prophylaxis , the question remains unanswered in larger part of it . whether to give prophylactic antibiotics or not would ultimately need a shared decision - making involving both the treating physician and the parents assessing both the risks and the benefits .
lastly , until proven otherwise by a prospective , randomized , and double - blind placebo - controlled study , it looks sensible to err on the side of caution .
 objectives : the aim of this review was to systematically examine the available evidence for the effectiveness of prophylactic antibiotics in cases of vesicoureteric reflux ( vur).materials and methods : we searched the relevant data on medical management of vur and the date of last search was june 2008 . 
 the search included both randomized controlled trials as well as the nonrandomized trials and the data sources were ; medline , online peer reviewed journals , cochrane database and abstracts from conference proceedings.results:barring few most of the studies published on medical management were nonrandomized . 
 besides being small in number many of these studies were of poor - quality and poorly designed eventually failing in giving a reliable answer in this regard . 
 few of the studies suggest that the children with low grade vur might do well even without antibiotic prophylaxis.conclusions:in the absence of properly designed , randomized controlled trials and long - term follow - up the question of antibiotic prophylaxis in cases of vur remains unanswered in large part of it . whether to give prophylactic antibiotics or not would ultimately need a shared decision - making involving both the treating physician and the parents assessing both the risks and the benefits . 
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INTRODUCTION
DISCUSSION
CONCLUSIONS