AAP guidelines on UTI management remain controversial

NEW ORLEANS — There has been some controversy over the AAP’s updated guidelines on urinary tract infections, particularly guideline No. 6, but it is important for clinicians to remember that the recommendations are based on the most currently available data, all of which have limitations, according to a speaker here at the 2012 American Academy of Pediatrics National Conference and Exhibition.

Robert D. Fildes, MD, medical director for the Inova Pediatric Kidney Center in Fairfax, Va., said the important take-home message of the guidelines are: “Bagged specimens have a high false-positive rate, and conducting a voiding cystourethrogram after an infant’s first UTI is probably not necessary, unless complex clinical circumstances or abnormal ultrasound findings suggest differently, and antimicrobial therapy may or may not be beneficial for preventing UTIs in children with lower-grade vesicoureteral reflux (VUR).”

Robert D. Fildes

Some of these recommendations were based on limited data, which prompted controversy when the guidelines were published last October, but Fildes said the panel should be commended for putting together such a comprehensive guidance for clinicians.

In the guideline, which is an update of the panel’s 1999 guideline, the AAP’s Subcommittee on Urinary Tract Infection urged prompt diagnosis and treatment of febrile UTIs in children aged younger than 2 years. The panel recommended using urinalysis and culture of urine obtained via bladder catheterization or suprapubic aspiration if an infant has a fever of unknown origin and the clinician is considering using antimicrobials. However, the panel also said if a clinician determines a low likelihood of UTI, he could, after careful urinalysis, elect to monitor without additional testing, which is a change from the panel’s 1999 guideline.

The revised guidelines recommended 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 recommended renal and bladder ultrasound in all febrile infants with confirmed UTIs.

In addition, the guidelines also addressed antimicrobial use, noting that the choice should be based on local antimicrobial susceptibility patterns because oral and parenteral treatments 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.

Discussing his personal approach to the guidelines, Fildes said he treats most children aged older than 2 months as outpatients and considers hospitalization or parenteral therapy for those aged younger than 2 months who are clinically unresponsive or immunocompromised.

Fildes said he initiates early empirical antimicrobial therapy after obtaining a proper specimen. Regarding imaging, he conducts imaging after the first febrile UTI in children aged younger than 2 years, particularly if a normal renal ultrasound is not obtained. He typically reserves voiding cystourethrogram for any child with two or more febrile UTIs, or those children with complex clinical circumstances, including a first febrile UTI and a family history of VUR.

Regarding VUR, Fildes said additional data from the Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) study will hopefully shed more light on whether all children with VUR should be treated with antibiotics, but that study is still a few months away from publication.

For more information:

Fildes RD. Abstract X1005. Presented at: AAP National Conference and Exhibition; Oct. 20-23, 2012; New Orleans.

Disclosure: Fildes reports no relevant financial disclosures.