UTI in Children and MCU

From Medscape Pediatrics > Viewpoints

Judicious Urinary Tract Imaging in Pediatric UTI

William T. Basco, Jr., MD, MS

Posted: 02/03/2012

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Impact of a More Restrictive Approach to Urinary Tract Imaging After Febrile Urinary Tract Infection

Schroeder AR, Abidari JM, Kirpekar R, et al
Arch Pediatr Adolesc Med. 2011;165:1027-1032

Study Summary

In 2007, the United Kingdom instituted updated guidelines for the management of urinary tract infection (UTI) in children. The guidelines recommend more limited use of renal ultrasound (RUS) and voiding cystourethrogram (VCUG). The UK guidelines recommend RUS for most children with UTI but limit the use of VCUG to children meeting the following criteria:

• UTI with bacteremia;
• inadequate clinical response in the first 48 hours;
• UTI caused by pathogens other than Escherichia coli;
• any clinical indication of poor urine flow;
• elevated serum creatinine level;
• palpable abdominal mass; or
• abnormal findings on the initial RUS.

The new guidelines do not generally recommend prophylactic antibiotics.

This study by Schroeder and colleagues reports the implementation of the UK guidelines to a medical center in California in September 2008, with periods of data collection corresponding to 1 year before and after implementation of the algorithm, separated by a period of time during which the new guidelines were being implemented. This study was conducted to determine how implementation of these guidelines affected the ordering of urinary tract imaging after UTI and whether the guidelines led to changes in prophylactic antibiotic use. They also compared the frequency of recurrent UTI before and after instituting the restricted guidelines.

The subjects of the analysis were children under 2 years of age. Urine cultures positive for pathogens were identified using clinical databases, the medical records for each child were reviewed, and any second UTI within 6 months of the index UTI was defined as a "recurrent UTI." Children with previous UTIs, genitourinary or neuromuscular abnormalities, or other conditions that might affect the results were excluded. The prealgorithm group included 98 children, and the postalgorithm group included 103. The groups were very similar at baseline.

A comparison of pre- and postimplementation findings includes the following:

• VCUG frequency declined from 99% to 12.6%.
• RUS frequency declined from 99% to 67%.
• Rates of recurrent UTI were almost identical, at 7.1% in the preguideline children compared with 7.8% in the postguideline children (not statistically significant).
• Frequency of grade 4-5 vesiculoureteral reflux was not different preguideline (2.0%) vs postguideline (2.9%)
• No grade 1-3 vesiculoureteral reflux was identified after implementation of the guidelines.
• Almost complete elimination of prophylactic antibiotic use was seen between completion of treatment for UTI and VCUG attainment.
• Indefinite prophylaxis with antibiotics decreased from 26.5% prealgorithm to 2.9% postalgorithm.
• Frequency of obtaining follow-up cultures for any reason between the 2 groups was identical, at 0.3%-0.4%.

The main effect of following the more restricted guidelines for post-UTI imaging was in not identifying low-grade vesiculoureteral reflux. Furthermore, fewer children received prophylactic antibiotics. Schroeder and colleagues support the application of this more restricted approach to the child with UTI.

Viewpoint

Many readers will be familiar with the updated American Academy of Pediatrics (AAP) guidelines for diagnosis and management of UTI in children,^[1] released in the fall of 2011. Those guidelines suggest the basic approach outlined in this article with respect to the first febrile UTI. The change in guidelines was prompted by building evidence that most children with high-grade reflux will have an abnormal RUS during the acute illness, allowing the clinician to avoid obtaining a VCUG in children whose initial RUS is normal. Viewing the results another way, most of the reflux identified through universal VCUG testing will be low grade and clinically inconsequential. I suspect that over the next 5 years we will see additional publications reporting short-term outcomes (1-5 years) in children with UTI after widespread implementation of the AAP guideline in the United States.