What are the guidelines for using a medication cap or determining the need for a dental cap?

Understanding the Question

The question "Cap" is unclear and lacks sufficient context to provide a meaningful medical recommendation. The expanded question suggests two possible interpretations: (1) guidelines for using a medication cap, or (2) determining the need for a dental cap. However, the provided evidence exclusively addresses community-acquired pneumonia (CAP) treatment guidelines and vesicoureteral reflux (VUR) with continuous antibiotic prophylaxis (CAP).

Given the evidence base, I will interpret this question as asking about Continuous Antibiotic Prophylaxis (CAP) in the context of vesicoureteral reflux in children, as this is the only "CAP" topic substantively covered in the guidelines provided.

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Continuous Antibiotic Prophylaxis (CAP) for Vesicoureteral Reflux in Children

Primary Recommendation

CAP should be used selectively based on individual risk factors rather than routinely for all children with VUR, with the strongest benefit seen in toilet-trained children with bladder-bowel dysfunction (BBD), high-grade VUR (III-V), young age (<12 months), and bilateral VUR. 1

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Risk-Stratified Approach to CAP

High-Risk Patients Who Benefit Most from CAP

• Children with grade III, IV, or V VUR show modest benefit from CAP, with a number needed to treat of 7 children for 2 years to prevent one febrile UTI, though without impact on kidney scarring or function. 1
• Uncircumcised males, presence of BBD, and high-grade reflux constitute a high-risk group that derives significant benefit from CAP according to RIVUR study risk classification. 1
• Toilet-trained children and those with lower urinary tract dysfunction (LUTD) derive better benefit from CAP than non-toilet-trained infants. 1
• Younger age at initial diagnosis (<12 months) and bilateral VUR are independent risk factors for breakthrough febrile UTIs, making CAP more beneficial in these populations. 1

Low-Risk Patients Where CAP Provides Minimal Benefit

• Children with low-grade reflux (grades I-II) show none or minimal benefit from CAP, and prophylaxis is not required for every VUR patient. 1
• Asymptomatic VUR diagnosed during antenatal hydronephrosis workup has ambiguous evidence regarding CAP benefit, and the literature remains unclear whether infants with asymptomatic VUR should receive prophylaxis. 1

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Antibiotic Selection and Dosing

First-Line Agents

• Trimethoprim-sulfamethoxazole (TMP-SMZ) at a quarter to half of the regular therapeutic dose is the most commonly used agent for CAP. 1
• Amoxicillin at prophylactic dosing (quarter to half therapeutic dose) is an alternative first-line option. 1
• Nitrofurantoin at prophylactic dosing is another commonly used agent. 1

Critical Age-Related Contraindications

• TMP-SMZ must be avoided in infants <6 weeks old due to risk of hepatic injury and in children with severe renal insufficiency due to potential kidney toxicity. 1
• Nitrofurantoin is best avoided before age 4 months due to risk of hemolytic anemia. 1

Management of Breakthrough Febrile UTIs

• In children with breakthrough febrile UTI on CAP, switch to an alternative antibiotic class using antibiogram guidance when available. 1
• Children with febrile UTI and high-grade VUR can still be considered for continued medical treatment, with surgical intervention reserved for CAP noncompliance, breakthrough febrile UTIs despite CAP, and symptomatic VUR (recurrent flank pain with or without febrile UTIs) that persists during long-term follow-up. 1

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Duration of CAP

General Principles

• The optimal timing for CAP discontinuation is controversial, but a practical approach is to continue CAP until BBD resolution. 1
• Patients who received CAP for <1 year after the last febrile UTI and those with bilateral VUR are likely to have more frequent recurrences after discontinuation. 1

Individualized Decision-Making

• The surveillance protocol and decision to perform antireflux procedure or discontinue CAP should incorporate shared decision-making with patient and caregivers, discussing risks, benefits, and alternatives in detail, with consideration of access to healthcare during febrile UTIs. 1

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Monitoring and Safety

Laboratory Monitoring

• TMP-SMZ prophylaxis for 2 years was not associated with adverse effects on complete blood count, serum electrolytes, or creatinine in the RIVUR study, and routine laboratory tests in otherwise healthy children are not mandatory. 1

Antibiotic Resistance Concerns

• CAP is associated with increased occurrence of non-E. coli organisms and antibiotic resistance, which must be weighed against the modest benefit in preventing febrile UTIs. 1
• The impact of long-term CAP on gut microbiota in children with VUR is controversial and requires further research. 1

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Critical Pitfalls to Avoid

• Do not use CAP routinely for all children with VUR, as low-grade reflux shows minimal benefit and CAP increases antibiotic resistance. 1
• Do not prescribe TMP-SMZ to infants <6 weeks old or nitrofurantoin to infants <4 months old due to serious adverse event risks. 1
• Do not discontinue CAP prematurely (<1 year after last febrile UTI), particularly in children with bilateral VUR, as this increases recurrence risk. 1
• Do not ignore BBD management, as toilet-trained children with LUTD derive the most benefit from CAP, and prophylaxis should ideally continue until BBD resolution. 1