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Debate continues over optimal UTI management
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There is some debate as to whether excluding the voiding cystourethrogram after a first urinary tract infection with fever is the best approach to addressing younger patients with a urinary tract infection.
Julian Wan, MD, and colleagues from the executive committee of the AAP Section on Urology, wrote in Pediatrics recently that the studies that AAP used to revise urinary tract infection (UTI) treatment guidelines are flawed for several reasons.
“The recommendation is based on several recent studies comparing antibiotic prophylaxis with no prophylaxis in children with vesicoureteral reflux (VUR), with the conclusion that it is not worth making the diagnosis of VUR,” Wan and colleagues wrote. “We believe that these conclusions are premature and represent a misinterpretation of the data presented.”
Supporting studies were small and used bag collection for urine samples when urethral catheterization or suprapubic aspiration are superior methods for specimen collection as acknowledged by AAP guidelines. In addition, the researchers said, the study did not account for uncircumcised boys aged younger than 1 year, who are prone to febrile UTI; bag specimens are not very accurate for this population. There is also no acknowledgement of bladder and bowel habits in most of the studies or in the guidelines, “which have significant impact on VUR reflux outcomes.” The section states that omitting the voiding cystourethrogram for the purpose of reducing renal scarring “is a value judgment, not a scientific conclusion, and should be discussed and acknowledged as such.”
In a reply to the committee statement, Kenneth B. Roberts, MD, and colleagues, of the department of pediatrics at the University of North Carolina Medical School in Chapel Hill, said there is a flaw in use of bag collection, but “the relative effectiveness of prophylaxis would appear to be reduced, but, of greater importance, any absolute difference in effectiveness would remain.”
Roberts and colleagues also wrote that most of the patients were girls, and regarding the sample size, the meta-analysis was used to determine statistical significance. Also, bladder and bowel habits are not easily assessed in infants aged 2 to 24 months, so it is not clear how much of a factor this would be.
“Regarding noncompliance, the studies were analyzed according to intention to treat. This is the preferred analytic approach in this situation, as it seems unlikely that compliance would be better in the usual clinical situation than in a study in which parents signed informed-consent forms and had their attention focused on administering the antimicrobial daily,” the researchers wrote. “We are pleased that the [Section on Urology] membership is actively engaged in research but would ask that it focus on demonstrating prevention of renal damage and loss of renal function. This is specifically identified as a critical area for research to inform the next revision of the AAP Guideline.”
References:
- Roberts KB. Pediatrics. 2012;doi:10.1542/peds.2011-3860.
- Wan J. Pediatrics. 2012;doi:10.1542/peds.2011-3615.
Disclosure:
- The researchers report no relevant financial disclosures.
Perspective
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Stan L. Block, MD
What's a poor pediatric practitioner to do when experts cannot agree? Let's explore some practical issues of the VCUG dilemma for first febrile UTI after age 6 months.
As I see it, first all of our experts assume that we can expeditiously obtain a catheterized urine for urinalysis and urine culture on every suspicious febrile child. This is technically difficult and labor intensive in young children for a multitude of reasons, and it also subsequently ruins our future ease of physical examinations in the 6- to 24-month-old child. For less ill or mildly ill children who need a urine work-up, it may be more palatable for us to obtain a bagged urinalysis in the office (<1 hour on) as a screening tool if possible. If the bagged urinalysis is totally negative (in the large majority), this should be enough proof that a negative UA and culture would also be seen on a catheterized urine as well. Otherwise, any positive findings via "bag" will require the more invasive catheterization to confirm UA findings and ultimately the gold standard method for urine culture. As far as the suprapubic tap, this procedure is rarely taught anymore in training programs, and is usually met with much reluctance by parents, as I can testify. And it can really only be easily performed in infants aged younger than 4 to 6 months as well.
After the first febrile UTI in the young child, I think that the renal sonogram is an adequate cost-effective screen initially. Here, the sonogram's major purpose is to detect the kidney, which is dilated, hydronephrotic, cali- or pelvic-actetic, duplicated, etc., or has typical identifiable appearance of grade 3-5 reflux. Any of these easily discernible major findings would then warrant careful management, VCUG and/or a DMSA scan. Conversely, if the renal sonogram is negative, then the kidney is either normal, or has at worst a grade 1 or 2 vesicoureteral reflux (which will not show up). Looking at most of the data, Grades 1 and 2 do not need antibiotic prophylaxis or surgery, and the child can merely be observed (even if it were uncovered by VCUG) any way. Spontaneous resolution over time is the norm. This would also spare the significant cost, parental time and child trauma of VCUG. A second febrile UTI would then trigger the need for VCUG and possibly a DMSA scan.
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