Imaging After Urinary Tract Infection
Impact of a More Restrictive Approach to Urinary Tract Imaging After Febrile Urinary Tract Infection
Arch Pediatr Adolesc Med. 2011;165(11):1027-1032. doi:10.1001/archpediatrics.2011.178
Alan R. Schroeder, MD; Jennifer M. Abidari, MD; Rashmi Kirpekar, MD; John R. Hamilton, PhD; Young S. Kang, MD; VyThao Tran, MD; Stephen J. Harris, MD. Santa Clara Valley Medical Center, San Jose, California
As evidence has emerged to support a less aggressive approach to imaging and intervention in children following UTI, most paediatricians have greatly reduced their reliance on imaging and prophylactic antibiotics. For the former you can see some data I published at http://adc.bmj.com/content/94/12/927 - figure shown below for MCU.
In this study, the authors compared their use of imaging investigations and prophylactic antibiotics during 2 one year periods (2 years apart) – either side of a change in their adoption of new guidelines. They also studied some outcomes – the rates of recurrent UTI and diagnosis of higher grades of VUR.
There was a dramatic change in practice:
· MCU rate period A = 99% vs 13% in period B
· prophylactic antibiotics 97% in period A vs 5% in period B
There was no change in rates of detection of high grade VUR, nor of recurrent UTI in this period.
This was not an RCT, nor a study properly powered for equivalence (it had 201 subjects) but the results are reassuring in the light of change in Australian practice.
The article is available at: http://archpedi.ama-assn.org/cgi/content/short/165/11/1027 and I have copied the useful guideline of who to investigate and when below.
Abstract
Objectives To determine the impact of using an algorithm requiring selective rather than routine urinary tract imaging following a first febrile urinary tract infection (UTI) on imaging use, detection of vesicoureteral reflux (VUR), prophylactic antibiotic use, and UTI recurrence within 6 months.
Design Retrospective review comparing outcomes during periods before algorithm use (September 1, 2006, to August 31, 2007) and after algorithm use (September 1, 2008, to August 31, 2009). The new algorithm, which adapted recommendations from the United Kingdom's National Institute for Health and Clinical Excellence 2007 guidelines, was implemented in 2008. The algorithm calls for renal ultrasonography in most cases and restricts voiding cystourethrography for use in patients with certain risk factors.
Setting County health system.
Participants Children younger than 2 years with a first febrile UTI.
Intervention Selective algorithm for urinary tract imaging.
Main Outcome Measures Urinary tract imaging use, detection of VUR, prophylactic antibiotic use, and UTI recurrence within 6 months.
Results After introduction of the new algorithm, voiding cystourethrography and prophylactic antibiotic use decreased markedly. Rates of UTI recurrence within 6 months and detection of grades 4 and 5 VUR did not change, but detection of grades 1 to 3 VUR decreased substantially. Patients in the prealgorithm group with grades 1 to 3 VUR who would have been missed with selective screening underwent no interventions other than successive urinary tract imaging and prophylactic antibiotic use.
Conclusions By restricting urinary tract imaging after an initial febrile UTI, rates of voiding cystourethrography and prophylactic antibiotic use decreased substantially without increasing the risk of UTI recurrence within 6 months and without an apparent decrease in detection of high-grade VUR. Clinicians can be more judicious in their use of urinary tract imaging.
Mike
Prof Mike South,
Royal Children's Hospital, Parkville, Victoria 3052, Australia
