Quick Links

Share with Colleagues
Previous EBM Focus Issues
Become a DynaMed Reviewer
DynaMed Free Trial
Send Comment to Editor

Join Our Mailing List



Physicians: .25 AMA PRA Category I CreditsTM
Family Physicians: .25 Prescribed credits
Nurse Practitioners: .25 Contact hours

Release Date: July 9, 2014
Expiration Date: July 9, 2015

Estimated Completion Time: 15 minutes

There is no fee for this activity.

To Receive Credit

In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon above.

Program Overview

Learning Objectives

Upon successful completion of this educational program, the reader should be able to:

1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.

Faculty Information

Alan Ehrlich, MD
Assistant Clinical Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Senior Deputy Editor, DynaMed, Ipswich, Massachusetts, USA

Michael Fleming, MD, FAAFP
Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company


Dr. Ehrlich, Dr. Fleming, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

No commercial support has been received for this activity.

Accreditation Statements

ACCME: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Antidote Education Company and EBSCO Publishing. Antidote is accredited by the ACCME to provide continuing medical education for physicians. Antidote Education Company designates this enduring activity for a maximum of 0.25 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

AAFP: This enduring material activity, DynaMed EBM Focus Volume 9, has been reviewed and is acceptable for up to 15.25 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 5, 2014. Term of approval is for one year from this date. Each EBM Focus is approved for .25 Prescribed credits. Credit may be claimed for one year from the date of each update. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AANP: This program is approved for 0.25 contact hour(s) of continuing education by the American Association of Nurse Practitioners. This program was planned in accordance with AANP CE Standards and Policies and AANP Commercial Support Standards.

Program ID: 1405237H

Last week 461 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 165 articles were added to DynaMed content.

Based on criteria for selecting "articles most likely to change clinical practice," one article was selected by the DynaMed Editorial Team.

Antibiotic Prophylaxis May Reduce Recurrent Febrile or Symptomatic UTI in Children With Vesicoureteral Reflux
Reference: N Engl J Med 2014 Jun 19;370(25):2367 (level 2 [mid-level] evidence)

Vesicoureteral reflux (VUR) is present in about 39% of children presenting with symptomatic urinary tract infection, and has been associated with an increased risk of renal scarring in some studies (N Engl J Med 2003 Jan 16;348(3):195 full-text). There has been conflicting evidence for the benefit of antibiotic prophylaxis in reducing recurrent symptomatic UTIs in this patient population. A previous systematic review demonstrated lower rates of recurrent symptomatic UTI in favor of antibiotic prophylaxis, but these results were not statistically significant (Cochrane Database Syst Rev 2011 Jun 15;(6):CD001532). In addition, a separate meta-analysis found benefit for antibiotic prophylaxis in patients with high-grade VUR, although these results also did not reach statistical significance (Pediatrics 2011 Sep;128(3):595). The largest trial included in the systematic review and meta-analysis was a high-quality randomized trial aimed at preventing recurrent urinary tract infections (also including some children without VUR). This trial did show a reduction in recurrent symptomatic UTI at 1 year in patients receiving trimethoprim-sulfamethoxazole, but the results were not statistically significant in the subgroup of children with VUR (N Engl J Med 2009 Oct 29;361(18):1748). To help resolve this uncertainty, a recent randomized trial evaluated antibiotic prophylaxis with trimethoprim-sulfamethoxazole in 607 children aged 2-72 months with grade I-IV VUR.

Children were randomized to trimethoprim 3 mg/kg/day plus sulfamethoxazole 15 mg/kg/day orally vs. placebo and followed for 2 years. VUR was identified using voiding cystourethrogram, and 46.5% had grade III-IV VUR. All children had 1-2 previous urinary tract infections with fever ≥ 38 degrees C (100.4 degrees F), or UTI symptoms within 24 hours before or after urine collection. Follow-up data were available for 509 children (84%) at 1 year and 520 children (86%) at 2 years. Renal scarring was assessed with dimercaptosuccinic acid (DMSA) renal scintigraphy at baseline, 1 year, and 2 years. At baseline, resistance to trimethoprim-sulfamethoxazole in index UTI was present in 20% of the trimethoprim-sulfamethoxazole group vs. 22% of the placebo group. Treatment failure was defined as any of 2 febrile UTIs, 1 febrile UTI plus 3 symptomatic UTIs, 4 symptomatic UTIs, or new or worsening renal scarring at 1 year.

The rate of recurrence of febrile or symptomatic UTI at 2 years was 12.9% with trimethoprim-sulfamethoxazole vs. 23.6% with placebo (p < 0.001, NNT 10). Treatment failure occurred in 5% with trimethoprim-sulfamethoxazole vs. 9.6% with placebo (p = 0.04, NNT 22). The proportion of patients with both a recurrent febrile or symptomatic UTI and resistance to trimethoprim-sulfamethoxazole was 9% in the trimethoprim-sulfamethoxazole group vs. 5% in the placebo group. The rate of renal scarring was 11.9% with trimethoprim-sulfamethoxazole vs. 10.2% with placebo (not significant).

This new trial is the first to clearly show a reduction in the recurrence of febrile or symptomatic UTI in children with VUR receiving trimethoprim-sulfamethoxazole compared to placebo. However, the trial also showed numerically higher rates of resistance to the antibiotic at 1-2 years, and the long-term effects of this need to be considered. Several previous trials have failed to show statistically significant benefit for antibiotic prophylaxis in reducing recurrent febrile or symptomatic UTI in children with VUR, but these most recent data may tilt the balance in favor of prophylaxis in this patient population.

For more information see the Vesicoureteral reflux topic in DynaMed.

Earn CME Credit for reading this e-Newsletter. For more information on this educational activity, see the CME sidebar.

EBSCO Health Launches Pediatric Clinical Information Mobile App

PEMSoft Now Available For iPhone, iPad, and Android Devices

A mobile app designed specifically for pediatricians, emergency department physicians, physicians-in-training and other medical providers caring for children with acute illnesses and injury, is now available from EBSCO Health, the leading provider of clinical decision support solutions for the healthcare industry.

Designed by pediatricians, emergency physicians and other medical specialists, PEMSoft is a pediatric evidence-based point-of-care medical reference tool for hospitals, emergency departments, clinics, pediatric group practices, transport services, and medical schools. The vast content in PEMSoft addresses the entire spectrum of neonatal, infant, child, adolescent and young adult health. PEMSoft authors adhere to a strict evidence-based editorial policy focused on systematic identification, evaluation and consolidation of practice-changing clinical literature.

The PEMSoft Mobile app includes explicit step-by-step emergency critical care procedures, information about common pediatric signs and symptoms and content covering pediatric injuries and management approaches. More than 3,000 evidence-based pediatric topics and a similar number of medical illustrations, clinical images and videos are also available via the mobile app.

The PEMSoft Mobile App is accessible from both Apple and Android devices.

For more information and technical support, visit the PEMSoft Mobile Access page. To view the official press release, click here.

DynaMed Careers

Looking for a change? The DynaMed editorial team is expanding and looking for talented and driven individuals. Visit the links below to learn about these exciting opportunities.

Section Editor of Specialty Content

DynaMed Contribution Opportunities

DynaMed Peer Review
Editorial Policies for Reviewers
Education for Clinicians in Training

Call for Peer Reviews

We are currently seeking subspecialty reviewers for our Patient Education Resource Center (PERC). PERC provides fact sheets and discharge instructions for patients leaving the hospital or emergency room. These hand-outs fulfill the meaningful use requirements for the Medicare & Medicare Services Incentive Programs.

Click here to speak with us about becoming a peer reviewer.