A narrative review of the benefit-risk profile of nitrofurantoin prophylaxis for recurrent urinary tract infection in the pediatric population

Abstract

Recurrent urinary tract infections (UTIs) in pediatric patients pose a clinical challenge, particularly when accompanied by vesicoureteral reflux (VUR), given its association with long-term renal complications.  Prophylaxis using nitrofurantoin (NFT) is a commonly used strategy, although its application is controversial due to the heterogeneity and methodological limitations of existing studies. Although NFT demonstrates efficacy in certain pediatric subgroups, including patients with grade IV-V VUR or vesicoureteral dysfunction, its prolonged use has been linked to serious adverse reactions, such as pulmonary fibrosis and hepatotoxicity. These toxicities, while rare, can be serious, particularly in extended regimens lasting 6 months or more. Various clinical guidelines have reduced their recommendation for continuous antibiotic prophylaxis due to its limited proven efficacy in preventing permanent kidney damage and increasing bacterial resistance. The need for individualized assessment, including risk factors, urinary anatomy, infection history, and comorbidities, is underscored, with a focus on the judicious use of antimicrobials. The use of antimicrobials in the prevention of recurrent UTIs in pediatric patients must be carefully weighed against their potential risks, using the lowest effective dose for the shortest time possible, with close monitoring and periodic reassessment of the indication.