A novel clinical score to predict breakthrough urinary tract infection in children with VUR: meta-analytic derivation and real-world validation.

BACKGROUND

Breakthrough urinary tract infection (BT-UTI) among children with vesicoureteral reflux (VUR) receiving continuous antibiotic prophylaxis (CAP) remains a clinical challenge with heterogeneous risk profiles and no validated prediction tools. We aimed to identify robust risk factors and develop an evidence-based predictive score for BT-UTI.

METHODS

We conducted a systematic review and meta-analysis following PRISMA and Cochrane guidance, searching PubMed, Web of Science, and Embase for cohort studies. Pooled effect estimates were calculated using appropriate fixed- or random-effects models; a scoring system was derived by natural logarithm transformation of pooled estimates. External validation used a cohort of 158 children with VUR receiving CAP at Children's Hospital of Chongqing Medical University (2021-2024).

RESULTS

Twenty-four cohort studies (n = 3,264) were included; pooled BT-UTI incidence was 30.5%. From 26 candidate factors, eight stable predictors were retained and incorporated into the score: age < 1 year (OR 2.04), bilateral reflux (OR 1.81), high-grade reflux IV-V (OR 2.65), symptomatic UTI (OR 2.74), history of recurrent UTI (OR 2.17), bladder and bowel dysfunction (BBD; OR 1.81), increased ureteral diameter ratio (UDR; MD 0.139), and DMSA renal scar formation (OR 4.40). External validation showed AUC 0.88 (95% CI 0.82-0.93); at a cutoff of 17 points accuracy was 0.84, and sensitivity 0.93. Calibration and decision-curve analyses indicated good agreement and a positive net clinical benefit.

CONCLUSIONS

We developed and externally validated an eight-item BT-UTI risk score for children with VUR on CAP that demonstrates high discrimination and clinical utility for individualized risk stratification and prevention planning and implementation guidance available.