A revised AAP clinical practice guideline on the diagnosis and management of the initial urinary tract infection (UTI) in febrile infants and young children is markedly different from the previous practice parameter published in 1999. New data have become available in the past five years, with the findings prompting a reexamination of the older studies. The notable changes are highlighted below:
The rationale for the biggest change — discouraging the routine performance of VCUGs — stems from analysis of the six recent randomized controlled trials of prophylaxis vs. no prophylaxis in young infants following a febrile UTI.
Prophylaxis was not demonstrated to be superior to no prophylaxis in preventing recurrence of febrile UTI in infants without reflux or in those with grades I-IV reflux. (In the studies, only five infants with grade V reflux were included, so the effectiveness of prophylaxis for infants with this grade of reflux is not known, but less than 1% of febrile infants with UTI have grade V reflux.)
Recurrent febrile UTI is less common among infants without high grade reflux, so waiting for the second UTI reduces the number of VCUGs performed by 90% and has a higher yield of infants with grades IV and V reflux. Studies of renal scarring suggest that waiting for the second UTI is acceptable and does not offset the benefit of sparing 90% of febrile infants with UTI the radiation, discomfort and cost of VCUG.
Reference: http://pediatrics.aappublications.org/content/128/3/595
- Diagnosis: The criteria for diagnosis now include an abnormal urinalysis as well as a positive culture containing ≥ 50,000 colony forming units/milliliter of a urinary pathogen. The abnormal urinalysis helps distinguish true UTI from asymptomatic bacteriuria. Guidance also is provided regarding assessment of the likelihood of UTI to help determine which febrile infants clinicians should evaluate for UTI.
- Treatment: Oral therapy is recognized as effective as parenteral therapy.
- Imaging: Renal-bladder ultrasonography (RBUS) should be performed, but voiding cystourethrography (VCUG) no longer is recommended routinely after the first febrile UTI. Indications for VCUG include findings on RBUS that suggest the presence of high grade vesicoureteral reflux or the recurrence of a febrile UTI.
- Follow-up: Emphasis should be on counseling families to seek medical evaluation promptly for UTI during future febrile illnesses.
The rationale for the biggest change — discouraging the routine performance of VCUGs — stems from analysis of the six recent randomized controlled trials of prophylaxis vs. no prophylaxis in young infants following a febrile UTI.
Prophylaxis was not demonstrated to be superior to no prophylaxis in preventing recurrence of febrile UTI in infants without reflux or in those with grades I-IV reflux. (In the studies, only five infants with grade V reflux were included, so the effectiveness of prophylaxis for infants with this grade of reflux is not known, but less than 1% of febrile infants with UTI have grade V reflux.)
Recurrent febrile UTI is less common among infants without high grade reflux, so waiting for the second UTI reduces the number of VCUGs performed by 90% and has a higher yield of infants with grades IV and V reflux. Studies of renal scarring suggest that waiting for the second UTI is acceptable and does not offset the benefit of sparing 90% of febrile infants with UTI the radiation, discomfort and cost of VCUG.
The figures in this updated guideline are worth scanning, including factors influencing the likelihood of UTI in febrile male & female infants; choices for parenteral and oral treatment of UTIs; sensitivity & specificity of diagnostic tests for UTI in infants; and a clinical practice guideline algorithm.
Reference: http://pediatrics.aappublications.org/content/128/3/595
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