236 / Urology

Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and
Management of the Initial UTI in Febrile Infants and Children 2 to
24 months
Subcommittee on Urinary Tract Infection, Steering Committee on Quality
Improvement and Management
Pediatrics 128:595-610, 2011

Objective.dTo revise the American Academy of Pediatrics practice

parameter regarding the diagnosis and management of initial urinary
tract infections (UTIs) in febrile infants and young children.
Methods.dAnalysis of the medical literature published since the last
version of the guideline was supplemented by analysis of data provided by
authors of recent publications. The strength of evidence supporting each
recommendation and the strength of the recommendation were assessed
and graded.
Results.dDiagnosis is made on the basis of the presence of both pyuria
and at least 50 000 colonies per mL of a single uropathogenic organism in
an appropriately collected specimen of urine. After 7 to 14 days of antimi-
crobial treatment, close clinical follow-up monitoring should be main-
tained to permit prompt diagnosis and treatment of recurrent infections.
Ultrasonography of the kidneys and bladder should be performed to detect
anatomic abnormalities. Data from the most recent 6 studies do not
support the use of antimicrobial prophylaxis to prevent febrile recurrent
UTI in infants without vesicoureteral reflux (VUR) or with grade I to IV
VUR. Therefore, a voiding cystourethrography (VCUG) is not recommen-
ded routinely after the first UTI; VCUG is indicated if renal and bladder
ultrasonography reveals hydronephrosis, scarring, or other findings that
would suggest either high-grade VUR or obstructive uropathy and in
other atypical or complex clinical circumstances. VCUG should also be per-
formed if there is a recurrence of a febrile UTI. The recommendations in this
guideline do not indicate an exclusive course of treatment or serve as a stan-
dard of care; variations may be appropriate. Recommendations about anti-
microbial prophylaxis and implications for performance of VCUG are
based on currently available evidence. As with all American Academy of
Pediatrics clinical guidelines, the recommendations will be reviewed
routinely and incorporate new evidence, such as data from the Randomized
Intervention for Children With Vesicoureteral Reflux (RIVUR) study.
Conclusions.dChanges in this revision include criteria for the diagnosis
of UTI and recommendations for imaging.
:

The new American Academy of Pediatrics (AAP) urinary tract infections guide-
lines update guidelines previously issued in 1999. This guideline recommends
selective testing for UTI in febrile children. Table 1 in the guideline delineates
the probability of UTI. The AAP recommends a high index of suspicion and recog-
nizes that urine samples should be obtained in many more children than will actu-
ally have a UTI (33/1). The rationale for this recommendation is prevention of
scarring and other sequelae of UTI. There is no cookbook approach to evaluation,
 Chapter 29ePediatric Urinary Tract Infection / 237

and there is a need to factor the severity of illness and the reliability of the care-
givers to follow up.
The guidelines cite the good evidence that in most instances, oral antibiotics
are as effective as parenteral therapy. Oral therapy should be utilized in the
absence of clinical contraindications.
While the majority of renal anomalies are now detected with prenatal imaging,
an ultrasound scan is still recommended after the first febrile UTI in all children.
However, the current guideline states that if a renal ultrasound scan is normal,
a VCUG should not be routinely obtained after a febrile UTI. However, most chil-
dren with reflux have normal renal ultrasound scans. Additionally, a normal renal
ultrasound scan does not exclude the presence of renal inflammation that poten-
tially results in renal scarring.
There are 2 downsides to a VCUG. One is the discomfort associated with the
test. The second is the identification and overtreatment of reflux. The guidelines
committee concludes that detection is of little benefit. This is largely based on
recent trials that show little to no benefit of antibiotic prophylaxis in low-grade
reflux. However, children with high-grade reflux are at risk for recurrent infec-
tions and, based on trials, are most likely to develop renal scarring and benefit
from prophylaxis. The International Reflux Study found a similar incidence of
scarring in the surgical and antibiotic arms, but surgery clearly decreased the
incidence of febrile UTI.
It is clear that it is very unlikely that a 5-year-old with a first febrile urinary tract
infection and a normal renal ultrasound scan has significant reflux. The natural
history in this child reveals a low risk for UTI. A 3-month-old with bacteremia
secondary to UTI should have a cystogram regardless of the ultrasound scan
findings. If the VCUG is normal, the family is reassured. If reflux is identified,
then the physician and family can ascertain risk and determine if antibiotic
prophylaxis or observation is the best course of action.
D. E. Coplen, MD

Prediction of Moderate and High Grade Vesicoureteral Reflux After a First

Febrile Urinary Tract Infection in Children: Construction and Internal
Validation of a Clinical Decision Rule
Leroy S, Romanello C, Smolkin V, et al (Univ of Oxford, UK; Univ of Udine,
Italy; Ha’Emek Med Ctr, Afula, Israel; et al)
J Urol 187:265-271, 2012

Purpose.dUrinary tract infection leads to a diagnosis of moderate or high

grade (III or higher) vesicoureteral reflux in approximately 15% of children.
Predicting reflux grade III or higher would make it possible to restrict cystog-
raphy to high risk cases. We aimed to derive a clinical decision rule to predict
vesicoureteral reflux grade III or higher in children with a first febrile urinary
tract infection.
Materials and Methods.dWe conducted a secondary analysis of prospec-
tive series including all children with a first febrile urinary tract infection
from the 8 European participating university hospitals.