VCUG Is Not Recommended for First Time UTI; AAP Issues Guidelines for UTI Management in Children

Link to Article: http://pediatrics.aappublications.org/content/128/3/595.full.pdf

Pediatrics; originally published online August 28, 2011;

Article Review:

In August 2011, the American Academy of Pediatrics (AAP) published new guidelines for the diagnosis and management of first-time febrile urinary tract infections in children.  These guidelines signal a departure from the standard management previously employed, specifically over VCUG imaging.  

After a thorough meta-analysis review of the literature, the AAP announced that its report was “developed to inform the revised, evidence-based, clinical guideline regarding the diagnosis and management of initial UTIs in febrile infants and young children, 2 to 24 months of age.”

The authors note that most children, who have grade I-IV vesicoureteral reflux, do not benefit from prophylactic antibiotics as they will not prevent recurrent febrile UTI’s.

Highlights of the AAP’s report:

·        Initiation of antibiotics early in a febrile UTI illness prevents renal damage.

·        If both pyuria and bacteriuria on microscopy are noted on the initial urinalysis, empiric antibiotics should be initiated while awaiting culture results.

·        Oral antibiotics are as effective as parenteral therapy.  Therefore, if the child is not vomiting and can tolerate orals, IM or IV Ceftriaxone should be avoided. Ceftriaxone can be given as initial treatment if child is vomiting and then switch to orals.

·        Urine culture should be obtained via catheterization as bag specimens are unreliable.

·        A culture result of 50,000 CFU/ml of a single known urinary pathogen is diagnostic for UTI.

·        To rule out anatomic abnormalities, an ultrasound should be obtained after the first febrile UTI in children 2 to 24 months of age; ideally performed at least one week after completing a course of antibiotics.

·        VCUG is recommended if the renal and bladder ultrasound show hydronephrosis, scarring, anatomic abnormalities or other evidence of ureteral obstruction

·        A VCUG is also recommended for a second febrile UTI, as the risk of Grade IV to V VUR is estimated to be 18% in this setting.

·        Evidence shows that antibiotic prophylaxis does not prevent recurrent febrile UTI’s in children with Grade I-IV Vesicoureteral reflux.  Thus a VCUG is not recommended following the first febrile UTI as it will not affect management of the patient.

·        Close clinical follow-up should be maintained following a UTI diagnosis.

Editor’s Commentary:

These AAP guidelines help clarify proper management of children ages 2 months to 24 months with urinary tract infections.  A catheterized urine specimen should be obtained in these children who present with fever and no obvious source of infection.  A urinalysis and microscopy should be obtained expeditiously. If both pyuria and bacteriuria are noted, oral antibiotics should be initiated pending culture results.  Close clinical follow-up should be arranged for these patients.

If a UTI is diagnosed per culture results, a renal bladder ultrasound should be obtained following resolution of the illness.  A VCUG should follow only if: (1) This is a recurrent febrile UTI, or (2) The renal bladder ultrasound is abnormal.   The pediatrician should have a low threshold for obtaining a urine specimen in a febrile child without a source, especially if that child has a previous history of a febrile UTI.

Commentary by Anne Sullivan, MD , Pediatric Nephrology, Kaiser Oakland:

The most important question to ask oneself when thinking about the work-up following a diagnosis of febrile urinary tract infection (UTI) is: "Will the results of this test change my clinical management?”

If an ultrasound is normal with no hydronephrosis and the infant or child has not had recurrent febrile UTIs, he or she is unlikely to have high-grade vesicoureteral reflux (VUR).  Moreover, these patients are likely to have no VUR or low-grade VUR. Therefore, a VCUG will not change our clinical management. However, if there is moderate or severe hydronephrosis on ultrasound, or there are recurrent febrile UTIs, then the likelihood of finding a high-grade VUR is higher and thus obtaining a VCUG in that patient would be appropriate.

The other important question to ask is if the parents are open to the possibility of surgical repair should high grade VUR be found on VCUG. If they are not open to the possibility of surgical repair, then it may not make sense to move forward with VCUG testing at that time, as the test would not affect clinical management. However, if the parents are open to surgical repair, then finding VUR may affect clinical management and thus it would be reasonable to obtain a VCUG.

Regardless of the discussions that surround treatment and further imaging studies in the setting of febrile UTIs, close follow-up is of the utmost importance. All children with a history of febrile urinary tract infection need to be followed closely over time for the development of recurrent febrile UTIs, hypertension or hematuria/proteinuria that may increase the suspicion of underlying renal scarring.

Commentary by Andrew Huang, MD, Pediatric Urology, Roseville:

The most recent AAP guidelines regarding UTI management in children represent a significant change from previous guidelines. A debate, however, still remains as to the significance of reflux and therefore its appropriate management.   Reflux is a heterogeneous and complex condition that can either be benign, serious leading to significant renal injury and lifelong issues, or somewhere within this spectrum.  The pediatric urology community supports some aspects of the new recommendations.  First and foremost is a catheterized collection of urine for culture—without which a true diagnosis of a UTI cannot be made. A renal bladder ultrasound should then be obtained following treatment of a febrile UTI illness, or sooner if the child is not responding to treatment as expected.  A VCUG should be obtained if the ultrasound is abnormal, or in “non-routine” cases such as recurrent febrile urinary tract infections or a family history of vesicoureteral reflux.  However, some urologists would still advocate a cystogram after the first documented febrile UTI.

Although the guidelines refer to studies that have suggested no benefit from antibiotic prophylaxis in preventing recurrent urinary tract infections in cases of VUR, there are limitations to these studies. Most of these studies included children with the diagnosis of a UTI based upon a bagged specimen.  And, most of these studies do not address the issue of compliance with prophylaxis.  For boys, many of the studies do not address circumcision status. Most of the children in the studies with vesicoureteral reflux had low to moderate grades of reflux (I-III) and these children are less likely to have recurrent infections or renal scarring and therefore not have a measurable benefit from prophylactic antibiotics. 

Further studies are clearly needed regarding these issues.  A promising study is the RiVUR study that is evaluating children with documented vesicoureteral reflux.  This is a prospective, placebo controlled study examining the use of trimethoprim/ sulfamethoxazole as prophylaxis in children with VUR. Until the picture is clearer, one of the most important factors may be the role of parental preference.  The pediatrician should have a discussion with the family about the risks of recurrent UTI’s, role of a cystogram and the medical and surgical management for reflux.