The impact of therapeutic delay time on acute scintigraphic lesion and ultimate scar formation in children with first febrile UTI

Oh, Mi Mi; Kim, Jin Wook; Park, Min Gu; Kim, Je Jong; Yoo, Kee Hwan; Moon, Du Geon

doi:10.1007/s00431-011-1614-3

Cited by 54 publications

(31 citation statements)

References 25 publications

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“…In agreement with our findings, the guidelines recently issued by the European Association of Urology recommend the use of VCUG in all young children with first febrile UTIs (Tekgül et al 2012). Given the strong association between therapeutic time delay and renal scarring (Oh et al 2012), it is essential to diagnose the children with high grade VUR, which increases the risk of developing febrile UTIs and renal scarring (Coulthard 2008).…”

Section: Discussionsupporting

confidence: 87%

Voiding Cystourethrography Is Mandatory in Infants with Febrile Urinary Tract Infection

Kimata¹,

Kitao²,

Yamanouchi³

et al. 2013

Tohoku J. Exp. Med.

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Vesicoureteral reflux (VUR) is common condition in infants with febrile urinary tract infections (UTIs). Both VUR and febrile UTIs are risk factors for renal scars, characterized by glomerular hypertrophy with global or segmental sclerosis as cardinal features in pathology. Because renal scars may cause hypertension or chronic kidney diseases in later life, voiding cystourethrography (VCUG) has been mandatory for infants following their first febrile UTIs to identify VUR. However, increasing evidence suggests that the presence of VUR may not represent a direct risk factor for renal scars, which has led to an increase in the use of a stratified approach, in which VCUG is not performed for all patients. This study was conducted to verify whether the stratified approach is justified to identify infants at risk for renal scarring. The medical records of 306 infants with first febrile UTIs (median age, 4 months; 0-72 months) were reviewed. VUR was detected in 40.4% (67/166) of patients by the non-stratified approach, in which VCUG was performed in all patients. In contrast, VUR was identified in only 27.1% (38/140) of patients by the stratified approach, in which VCUG was performed only in the patients with high risk of developing renal scars. This difference in the discovery rate was significant (p = 0.02). Renal bladder ultrasonography had the sensitivities of as low as 45.7% and 52.9% in detecting VUR and in predicting renal scarring assessed by renal scintigraphy, respectively. In conclusion, VCUG should be performed in all infants after their first febrile UTIs.

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Section: Discussionsupporting

confidence: 87%

Voiding Cystourethrography Is Mandatory in Infants with Febrile Urinary Tract Infection

Kimata¹,

Kitao²,

Yamanouchi³

et al. 2013

Tohoku J. Exp. Med.

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“…2,33,36,37 It is thought that renal scarring can be prevented if UTI is treated promptly with antibiotics, 2 and there is some evidence that a delay in the treatment of acute UTI is more likely to result in renal scarring. [38][39][40][41][42][43][44] Renal scarring has been associated with long-term complications including renal failure [end-stage renal failure (ESRF)], hypertension and pre-eclampsia. 2,[45][46][47] These are serious, chronic conditions responsible for significant morbidity and costs to the NHS.…”

Section: Longer-term Adverse Consequencesmentioning

confidence: 99%

The Diagnosis of Urinary Tract infection in Young children (DUTY): a diagnostic prospective observational study to derive and validate a clinical algorithm for the diagnosis of urinary tract infection in children presenting to primary care with an acute illness

Hay

Birnie²,

Busby³

et al. 2016

Health Technol Assess

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BackgroundIt is not clear which young children presenting acutely unwell to primary care should be investigated for urinary tract infection (UTI) and whether or not dipstick testing should be used to inform antibiotic treatment.ObjectivesTo develop algorithms to accurately identify pre-school children in whom urine should be obtained; assess whether or not dipstick urinalysis provides additional diagnostic information; and model algorithm cost-effectiveness.DesignMulticentre, prospective diagnostic cohort study.Setting and participantsChildren < 5 years old presenting to primary care with an acute illness and/or new urinary symptoms.MethodsOne hundred and seven clinical characteristics (index tests) were recorded from the child’s past medical history, symptoms, physical examination signs and urine dipstick test. Prior to dipstick results clinician opinion of UTI likelihood (‘clinical diagnosis’) and urine sampling and treatment intentions (‘clinical judgement’) were recorded. All index tests were measured blind to the reference standard, defined as a pure or predominant uropathogen cultured at ≥ 105colony-forming units (CFU)/ml in a single research laboratory. Urine was collected by clean catch (preferred) or nappy pad. Index tests were sequentially evaluated in two groups, stratified by urine collection method: parent-reported symptoms with clinician-reported signs, and urine dipstick results. Diagnostic accuracy was quantified using area under receiver operating characteristic curve (AUROC) with 95% confidence interval (CI) and bootstrap-validated AUROC, and compared with the ‘clinician diagnosis’ AUROC. Decision-analytic models were used to identify optimal urine sampling strategy compared with ‘clinical judgement’.ResultsA total of 7163 children were recruited, of whom 50% were female and 49% were < 2 years old. Culture results were available for 5017 (70%); 2740 children provided clean-catch samples, 94% of whom were ≥ 2 years old, with 2.2% meeting the UTI definition. Among these, ‘clinical diagnosis’ correctly identified 46.6% of positive cultures, with 94.7% specificity and an AUROC of 0.77 (95% CI 0.71 to 0.83). Four symptoms, three signs and three dipstick results were independently associated with UTI with an AUROC (95% CI; bootstrap-validated AUROC) of 0.89 (0.85 to 0.95; validated 0.88) for symptoms and signs, increasing to 0.93 (0.90 to 0.97; validated 0.90) with dipstick results. Nappy pad samples were provided from the other 2277 children, of whom 82% were < 2 years old and 1.3% met the UTI definition. ‘Clinical diagnosis’ correctly identified 13.3% positive cultures, with 98.5% specificity and an AUROC of 0.63 (95% CI 0.53 to 0.72). Four symptoms and two dipstick results were independently associated with UTI, with an AUROC of 0.81 (0.72 to 0.90; validated 0.78) for symptoms, increasing to 0.87 (0.80 to 0.94; validated 0.82) with the dipstick findings. A high specificity threshold for the clean-catch model was more accurate and less costly than, and as effective as, clinical judgement. The additional diagnostic utility of dipstick testing was offset by its costs. The cost-effectiveness of the nappy pad model was not clear-cut.ConclusionsClinicians should prioritise the use of clean-catch sampling as symptoms and signs can cost-effectively improve the identification of UTI in young children where clean catch is possible. Dipstick testing can improve targeting of antibiotic treatment, but at a higher cost than waiting for a laboratory result. Future research is needed to distinguish pathogens from contaminants, assess the impact of the clean-catch algorithm on patient outcomes, and the cost-effectiveness of presumptive versus dipstick versus laboratory-guided antibiotic treatment.FundingThe National Institute for Health Research Health Technology Assessment programme.

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“…A delay in treatment has been associated with a higher likelihood of renal scarring. [8][9][10][11] This may partly explain why, in a recent meta-analysis, children with UTIs caused by non-E coli organisms were more likely to develop renal scarring. 12 Our results suggest that pyuria may not always be present in children with UTIs, especially those caused by Enterococcus species, Klebsiella species, or P aeruginosa.…”

Section: Figurementioning

confidence: 99%

Association Between Uropathogen and Pyuria

et al. 2016

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OBJECTIVE: We sought to determine factors associated with the absence of pyuria in symptomatic children whose urine culture was positive for a known uropathogen. METHODS:We obtained data on children evaluated at the Children's Hospital of Pittsburgh emergency department between 2007 and 2013 with symptoms of urinary tract infection (UTI) who had paired urinalysis and urine cultures. We excluded children with an unknown or bag urine collection method, major genitourinary anomalies, immunocompromising conditions, or with multiple organisms on culture. We chose a single, randomly-selected urine specimen per child and limited the analysis to those with positive cultures.RESULTS: There were 46 158 visits during the study period; 1181 children diagnosed with UTI met all inclusion criteria and had a microscopic urinalysis for pyuria. Pyuria (≥5 white blood cells per high-powered field or ≥10 white blood cells per cubic millimeter) was present in 1031 (87%) children and absent in 150 (13%). Children with Enterococcus species, Klebsiella species, and Pseudomonas aeruginosa were significantly less likely to exhibit pyuria than children with Escherichia coli (odds ratio of 0.14, 0.34, and 0.19, respectively). Children with these organisms were also less likely to have a positive leukocyte esterase on dipstick urinalysis. Results were similar when we restricted the analysis to children whose urine samples were collected by bladder catheterization. CONCLUSIONS:We found that certain uropathogens are less likely to be associated with pyuria in symptomatic children. Identification of biomarkers more accurate than pyuria or leukocyte esterase may help reduce over-and undertreatment of UTIs.

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The impact of therapeutic delay time on acute scintigraphic lesion and ultimate scar formation in children with first febrile UTI

Cited by 54 publications

References 25 publications

Voiding Cystourethrography Is Mandatory in Infants with Febrile Urinary Tract Infection

Voiding Cystourethrography Is Mandatory in Infants with Febrile Urinary Tract Infection

The Diagnosis of Urinary Tract infection in Young children (DUTY): a diagnostic prospective observational study to derive and validate a clinical algorithm for the diagnosis of urinary tract infection in children presenting to primary care with an acute illness

Association Between Uropathogen and Pyuria

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