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Background <p>Antenatal hydronephrosis (HN) is the most common congenital urinary tract abnormality, but management is controversial. Current guidelines recommend continuous antibiotic prophylaxis (CAP), voiding cystourethrogram (VCUG), and diuretic renal scintigraphy (DRS) for high-grade HN, yet these measures may expose many asymptomatic infants to unnecessary antibiotics, radiation, and anesthesia. We evaluated whether a selective approach—reserving CAP for hydroureteronephrosis (HUN), limiting VCUG to HUN or confirmed urinary tract infection (UTI), and using DRS only when ultrasound trends were equivocal—could reduce interventions without increasing adverse outcomes.</p> Methods <p>We conducted a retrospective cohort study of 1,008 consecutive infants (&lt; 24&#xa0;months) with isolated HN or HUN (2015 and 2025). Patients were grouped by treatment era: 2015–2018 (pre-protocol), 2019–2021 (implementation), and 2022–2025 (post-clinic). Outcomes included use and duration of CAP, VCUG, and DRS, UTI incidence, and timing of surgery.</p> Results <p>VCUG (52% → 28%) and DRS (58% → 30%) use declined significantly over time. Median CAP duration decreased from 7.7 to 2.9&#xa0;months (<i>p</i> &lt; 0.001). Surveillance UTI rates remained stable (2–4%, <i>p</i> = 0.74). In isolated HN, CAP conferred no measurable benefit (number needed to treat [NNT] 100), whereas in HUN, CAP reduced infections (6% vs. 21%; NNT 27).</p> Conclusions <p>Selective management of antenatal HN—avoiding routine CAP, VCUG, and DRS in most infants—safely reduces unnecessary interventions without increasing UTI risk or delaying surgery. CAP should be reserved for higher-risk groups, such as infants with HUN, particularly uncircumcised males. These findings support updating international guidelines toward risk-based, individualized care.</p> Graphical abstract <p></p>

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Safely limiting the use of antibiotic prophylaxis and invasive testing in asymptomatic children with antenatally detected hydronephrosis

  • 期刊论文

  • 发表日期：

    2026年2月18日

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  • Mandy Rickard,
  • Adree Khondker,
  • Joana Dos Santos,
  • Samer Maher,
  • Innocent Nzeyimana,
  • Rahim Dhalla,
  • Nithiakishna Selvathesan,
  • Cal Robinson,
  • Ailish Coblentz,
  • Gillian Hunter,
  • Michael Chua,
  • Armando J. Lorenzo

摘要

Background

Antenatal hydronephrosis (HN) is the most common congenital urinary tract abnormality, but management is controversial. Current guidelines recommend continuous antibiotic prophylaxis (CAP), voiding cystourethrogram (VCUG), and diuretic renal scintigraphy (DRS) for high-grade HN, yet these measures may expose many asymptomatic infants to unnecessary antibiotics, radiation, and anesthesia. We evaluated whether a selective approach—reserving CAP for hydroureteronephrosis (HUN), limiting VCUG to HUN or confirmed urinary tract infection (UTI), and using DRS only when ultrasound trends were equivocal—could reduce interventions without increasing adverse outcomes.

Methods

We conducted a retrospective cohort study of 1,008 consecutive infants (< 24 months) with isolated HN or HUN (2015 and 2025). Patients were grouped by treatment era: 2015–2018 (pre-protocol), 2019–2021 (implementation), and 2022–2025 (post-clinic). Outcomes included use and duration of CAP, VCUG, and DRS, UTI incidence, and timing of surgery.

Results

VCUG (52% → 28%) and DRS (58% → 30%) use declined significantly over time. Median CAP duration decreased from 7.7 to 2.9 months (p < 0.001). Surveillance UTI rates remained stable (2–4%, p = 0.74). In isolated HN, CAP conferred no measurable benefit (number needed to treat [NNT] 100), whereas in HUN, CAP reduced infections (6% vs. 21%; NNT 27).

Conclusions

Selective management of antenatal HN—avoiding routine CAP, VCUG, and DRS in most infants—safely reduces unnecessary interventions without increasing UTI risk or delaying surgery. CAP should be reserved for higher-risk groups, such as infants with HUN, particularly uncircumcised males. These findings support updating international guidelines toward risk-based, individualized care.

Graphical abstract