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AAP updates UTI guidelines
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Conducting a voiding cystourethrogram after an infant’s first urinary tract infection is probably not necessary, unless ultrasound findings suggest abnormalities, according to an updated AAP practice guideline published online this week.
In the guideline, the AAP’s Subcommittee on Urinary Tract Infection urges prompt diagnosis and treatment of febrile urinary tract infections (UTI) in children aged younger than 2 years. The panel recommended using urinalysis and culture if an infant has a fever of unknown origin and the clinician is considering using antimicrobials. However, the panel also said a clinician should use his best judgment and could just follow-up with no urinalysis or culture, which is a change from the panel’s 1999 guideline.
The revised guidelines recommend obtaining a catheterized or suprapubic aspirate urine specimen for culture, and the AAP panel members said in their paper that urine culture should show at least 50,000 colony-forming units per milliliter of a single uropathogen to confirm etiology.
The guidelines recommend renal and bladder ultrasound in all febrile infants with confirmed UTIs. The panel also recommended reserving voiding cystourethrogram for use if renal and bladder ultrasonography reveals scarring or other findings suggestive of high-grade vesicoureteral reflux (VUR) or obstructive uropathy.
Antimicrobial use
In addition, the guidelines also address antimicrobial use, noting that the choice should be based on local antimicrobial susceptibility patterns because oral and parenteral treatment are equally efficacious. The guidelines recommend treatment duration should be 7 to 14 days, which the panel said was reflective of the most recently published data.
In a meta-analysis published last year, Infectious Diseases in Children Editorial Board member Alejandro Hoberman, MD, and colleagues said there may be a general movement away from prophylaxis. However, the Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) study, which is sponsored by the NIH and is currently being conducted by Hoberman and colleagues, may help end the debate on the effectiveness of prophylactic antibiotics in children with VUR to prevent recurrent UTIs and renal scarring.
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In the interim, in an accompanying study published alongside the guidelines, the panel wrote: “Meta-analyses of data from recent, randomized controlled trials do not support antimicrobial prophylaxis to prevent febrile UTI. This finding argues against voiding cystourethrography after the first UTI.”
Committee members wrote that their recommendations do not represent an exclusive course of treatment but are intended to guide clinicians in decision-making and, therefore, “variations may be appropriate.”
Help for clinicians
Writing in an accompanying editorial, Thomas B. Newman, MD, MPH, of the University of California, San Francisco, said these guidelines “represent a significant advance that should be helpful to clinicians and families dealing with this common problem.”
However, Newman said he took issue with the panel’s recommendation that the threshold probability for urine testing is less than 3%, “which indicates that it is worth performing urine tests on more than 33 febrile children to identify a single UTI. This is puzzling because the only study cited to support a specific testing threshold found that 33% of academicians and 54% of practitioners had a urine culture threshold.”
He wrote that the decision to test should be made on a case-by-case basis.
Disclosure: The researchers report no relevant financial disclosures.
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