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New evidence challenges need for prophylactic antibiotics, invasive scanning for some young children with UTIs

Tuesday, October 14 2008 | Comments
Evidence Grade 0 What's This?
By Yvonne Poindexter

Pediatricians have an increasing number of options available for diagnosing and treating urinary tract infections (UTIs) in young children, but studies to date do not provide clear evidence to guide clinical decisions.

"Practice guidelines issued by the American Academy of Pediatrics in 1999 offer clinicians some guidance," said Dr. Ron Keren of The Children's Hospital of Philadelphia, who presented with colleague Dr. Douglas Canning, chief of the urology division at Children's Hospital.

Even when the guidelines were issued, the evidence on which they were based was at best "fair," given the limited studies that had been done, according to Dr. Keren. In the years since, new treatment options and diagnostic technologies have emerged, and the handful of studies conducted since 2000 have only muddied the waters for evidence-based care for pediatric UTIs. A 2008 Cochrane review noted by the presenters concluded that large, properly randomized, double-blind studies are needed to determine the efficacy of long-term antibiotics for the prevention of UTI in susceptible children.

In the presentation, Dr. Keren and Dr. Canning challenged attendees to review the existing recommendations with a critical eye that takes into account the latest evidence and clinical insights. A key controversy is whether or not to use antibiotic prophylaxis for UTIs in young children. The goal of such treatment, in theory, is to prevent recurrent UTIs and pyelonephritis, a urinary infection of the kidneys. In some children, pyelonephritis leads to renal scarring, which in turn is associated with increased risk for hypertension, pre-eclampsia, and chronic renal disease later in life.

Because vesicoureteral reflux (VUR) is present in 25% to 40% of children with acute pyelonephritis, imaging is an essential diagnostic component, but evidence is sparse about what type of scans are most advantageous, according to Dr. Canning. To evaluate for VUR,  most authorities recommend a voiding cystourethrogram (VCUG) on all males and younger females after the first UTI.

A meta-analysis published in 2003, however, concluded that there is no strong evidence that any intervention with primary VUR does more good than harm, noted Dr. Keren. But he added, "The absence of evidence does not mean there's evidence of an absence of benefit."

"A primary consideration should be whether imaging results are likely to affect how each case is managed," said Dr. Keren. Clinicians should also be careful to distinguish between types of cases. With individualized care, for example, antibiotic prophylaxis and radiologic scanning would likely be advisable for a 5-month-old girl with febrile UTI requiring hospitalization who has a family history of VUR. These options may not make sense, however, for an afebrile 3-year-old girl who is going through potty training when she presents with her first UTI.

In managing cases, age is also an important consideration. Children aged younger than 1 year with a UTI are at much greater risk for renal scarring than older children; children aged older than 5 years do not commonly have new renal scarring with UTI. In some cases, however, it may be appropriate to forgo a full clinical work-up for a first UTI, adopting a wait-and-see approach with heightened vigilance, advised Dr. Keren.

In addition, pediatricians should be aware of 2 new developments--a new diagnostic approach that could help identify children at risk for renal scarring and a diagnostic insight that could help rule out children likely to have VUR. The new diagnostic approach has been dubbed the "top down approach," explained Dr. Keren. The strategy relies on a dimercaptosuccinic acid (DMSA) scan of the kidneys within 30 days of a UTI. If a child's DMSA scan is normal, the clinician and family have reassurance that the kidneys are normal and that the child is unlikely to have dilating VUR. A child with a febrile UTI who has a normal DMSA scan is very unlikely to have high-grade (>III) VUR, said Dr. Keren. A benefit of the DMSA scan is that for children with normal scans, it eliminates the need for the more standard VCUG, an invasive, potentially "traumatic" radiologic test, according to Dr. Keren.

An abnormal DMSA reading suggests that VUR or an obstruction may be present and that a VCUG should be performed. In these cases, patients may also benefit from surgery and/or prophylactic antibiotics. DMSA scanning may also prove helpful in identifying children who have renal scarring without VUR. "VUR is neither necessary nor sufficient to produced renal scarring," Dr. Canning added.

The second diagnostic insight worth careful consideration is the need to evaluate patients for dysfunctional elimination, an underlying condition that could make a child susceptible to UTIs. Evidence suggests that dysfunctional elimination is underdiagnosed and undertreated, explained Dr. Keren. Furthermore, treatment of the underlying condition, through behavioral therapy, laxatives, increased fluid intake, or other means as needed decreases UTI recurrence and speeds resolution of VUR.

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