Value of Imaging Studies After a First Febrile Urinary Tract Infection in Young Children: Data From Italian Renal Infection Study 1

Montini, Giovanni; Zucchetta, Pietro; Tomasi, Lisanna; Talenti, Enrico; Rigamonti, Waifro; Picco, Giorgio; Ballan, Alberto; Zucchini, A.; Serra, Laura; Canella, Vanna; Gheno, Marta; Venturoli, Andrea; Ranieri, Marco; Caddia, Valeria; Carasi, Carla; Dall’Amico, Roberto; Hewitt, Ian K.

doi:10.1542/peds.2008-1003

Cited by 100 publications

(76 citation statements)

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“…Many studies have similar limitations. 6,7,9,19,24 Other studies have limited generalizability owing to narrow 10,25 or broad [26][27][28] age ranges, or small sample size. 8,[26][27][28] One study looked specifically at the predictive value of ureteral dilation as an isolated finding on RBUS.…”

Section: Discussionmentioning

confidence: 99%

“…However, most of these papers have limitations that make it impossible to determine the test characteristics of RBUS; most common is that many studies do not provide sufficient data to directly compare RBUS findings with VCUG findings in individual patients. [12][13][14][15][16][17][18][19] Other studies focus on the value of RBUS to predict renal scintigraphic findings (scarring). 13,[20][21][22] Verification bias is a common weakness in the published literature.…”

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confidence: 99%

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Ultrasound as a Screening Test for Genitourinary Anomalies in Children With UTI

Nelson¹,

Johnson²,

Logvinenko

et al. 2014

Pediatrics

105

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WHAT'S KNOWN ON THIS SUBJECT: Current guidelines recommend renal ultrasound as a screening test after febrile urinary tract infection, with voiding cystourethrogram (VCUG) only if the ultrasound is abnormal. Few studies have evaluated the accuracy of ultrasound as a screening test for VCUG-identified abnormalities. WHAT THIS STUDY ADDS:This study shows that ultrasound is a poor screening test for genitourinary abnormalities identified on VCUG, such as vesicoureteral reflux. Neither positive nor negative ultrasounds reliably identify or rule out such abnormalities. Ultrasound and VCUG provide different, but complementary, information.abstract BACKGROUND: The 2011 American Academy of Pediatrics guidelines state that renal and bladder ultrasound (RBUS) should be performed after initial febrile urinary tract infection (UTI) in a young child, with voiding cystourethrogram (VCUG) performed only if RBUS shows abnormalities. We sought to determine test characteristics and predictive values of RBUS for VCUG findings in this setting. METHODS:We analyzed 3995 clinical encounters from January 1, 2006 to December 31, 2010 during which VCUG and RBUS were performed for history of UTI. Patients who had previous postnatal genitourinary imaging or history of prenatal hydronephrosis were excluded. Sensitivity, specificity, and predictive values of RBUS for VCUG abnormalities were determined. RESULTS:We identified 2259 patients age ,60 months who had UTI as the indication for imaging. RBUS was reported as "normal" in 75%. On VCUG, any vesicoureteral reflux (VUR) was identified in 41.7%, VUR grade .II in 20.9%, and VUR grade .III in 2.8%. Sensitivity of RBUS for any abnormal findings on VCUG ranged from 5% (specificity: 97%) to 28% (specificity: 77%). Sensitivity for VUR grade .III ranged from 18% (specificity: 97%) to 55% (specificity: 77%). Among the 1203 children aged 2 to 24 months imaged after a first febrile UTI, positive predictive value of RBUS was 37% to 47% for VUR grade .II (13% to 24% for VUR grade .III); negative predictive value was 72% to 74% for VUR grade .II (95% to 96% for VUR grade .III).CONCLUSIONS: RBUS is a poor screening test for genitourinary abnormalities. RBUS and VCUG should be considered complementary as they provide important, but different, information. Dr Nelson conceptualized and refined the study design, performed a substantial portion of data collection and interpretation, and drafted the initial manuscript; Dr Johnson contributed substantially to data collection and interpretation, critically reviewed the manuscript, and incorporated revisions from all the authors; Dr Logvinenko performed data analysis and critically reviewed the manuscript; Dr Chow contributed to conceptualization and refinement of the study design and data interpretation and critically reviewed the manuscript; and all authors approved the final manuscript as submitted. Although the new guidelines do not explicitly frame RBUS as a screening test, the guidelines do suggest that the decision to perform VCUG after a first febrile UTI...

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Ultrasound as a Screening Test for Genitourinary Anomalies in Children With UTI

Nelson¹,

Johnson²,

Logvinenko

et al. 2014

Pediatrics

105

View full text Add to dashboard Cite

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“…Montini et al analyzed data of 300 children with acute pyelonephiritis with USG evaluation and found that USG detected VUR only in 27.27%. The ability of USG to predict the renal parenchymal damage was also limited to only 26.66% and they were found to have parenchymal scarring by DMSA [8]. In our study, USG showed signs of pyelonephritis in 62(71.2%) children and cystitis in 25(28.8%).…”

Section: Discussionmentioning

confidence: 47%

“…The follow-up DMSA scan showed scarring in 28% of those with initial diagnosis of acute pyelonephritis. He concluded that DMSA should be done 6 months after infection to detect scarring that may be lead to hypertension and proteinuria [8]. In our center, DMSA in acute phase picked up acute pyelonephritis in 81.5% children, follow-up scan done between 6 months to 1 year revealed evidence of scars in 44(29.1%) children.…”

Section: Discussionmentioning

confidence: 72%

First Febrile Urinary Tract Infection – Clinico-Biological Correlation with Imaging Studies - A Prospective Study

Vijayakumar¹,

Geminiganesan²,

Priyadarshini³

et al. 2014

J Nephrol Ther

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Febrile urinary tract infection is one of the commonest infections in the childhood. Unrecognized and untreated childhood UTI can lead to scarring of the growing kidneys with subsequent hypertension and renal failure. This study has been done at a tertiary care medical centre to study the clinico -biological and imaging correlation in children with first episode of febrile UTI. Renal function tests, ultrasonogram, DMSA and MCU were done according to ISPN and institutional protocol. Imaging was done on follow up as per need. Majority of the children were found to be in 1 to 5 years age (68%) group and overall there was female preponderance (n=80; 53%). Dysuria was the commonest presentation in febrile UTI and E. coli, the commonest organism isolated. USG was found abnormal in 57.6% of children and DMSA done in acute phase picked up pyelonephritis in 81.5%. MCU revealed VUR in 39% of the study population. The study underlines the importance and efficacy of various investigations apart from the clinical presentation in diagnosing UTI and defining the associated risk factors.

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“…1 Like other studies of this topic, [2][3][4][5][6] this is a retrospective analysis of data captured through routine care, but it is probably the largest and most well-conducted study of its kind. Their findings are consistent with most earlier work, and their conclusions valid: RBUS is a lousy screen for vesicoureteral reflux (VUR).…”

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UTI and Watchful Waiting: The Courage to Do Nothing

Downs

2014

Pediatrics

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In this issue of Pediatrics, Nelson and colleagues present a retrospective cross-sectional study of children ,60 months of age who underwent renal and bladder ultrasound (RBUS) and voiding cystourethrogram (VCUG).1 Like other studies of this topic, [2][3][4][5][6] this is a retrospective analysis of data captured through routine care, but it is probably the largest and most well-conducted study of its kind. Their findings are consistent with most earlier work, and their conclusions valid: RBUS is a lousy screen for vesicoureteral reflux (VUR). Because the new American Academy of Pediatrics (AAP) guidelines 7 recommend routine RBUS after the first febrile urinary tract infection (UTI), the authors make the point that a negative RBUS should not be interpreted as ruling out VUR or other conditions detectible on VCUG. This raises an important point. The AAP guideline, in fact, recommends watchful waiting (for a second UTI), not RBUS, as the screening test for high-grade VUR.The AAP guideline suggests that, after the first UTI, the clinician should carefully observe the patient for a recurrence. A VCUG is recommended only after the second UTI. The rationale for this strategy is twofold. First, multiple studies show that children who have VUR are at increased risk for UTI. [8][9][10][11][12][13] Based on these data, the technical report that accompanies the AAP guideline 14 shows that watchful waiting can serve as a diagnostic test. Using the calculations in the technical report, it can be shown that a recurrent UTI has a positive predictive value of 55% for VUR of grade III or higher.By the same calculus, children who do not have recurrent UTI are less likely to have VUR. In fact, the negative predictive value of having no recurrent UTI is 81%. If these calculations are repeated with the lower prevalence of highgrade VUR described in Nelson et al, the negative predictive value is over 98%, meaning the risk for high-grade VUR would be ,2%. Moreover, because renal scarring among children who have VUR occurs with UTI, those children who do not have subsequent UTIs would not be expected to suffer renal damage. So even if therapy for VUR were known to improve long-term outcomes (and this has not been proven [15][16][17][18] ), the benefit of finding VUR in children who do not have a recurrent UTI is doubtful.The second reason for using watchful waiting as a screen for VUR is that 90% of children will never have a second UTI. 7 This means that 90% of children will not be exposed to the discomfort, expense, and radiation associated with a VCUG. Although VCUG is considered the gold standard for the detection of VUR, the tincture (or test) of time is a better screening test than RBUS but has none of the side effects of VCUG.So Nelson and colleagues' conclusion that RBUS is a poor screen for VUR is valid. In fact, the AAP guideline and technical report acknowledge the poor sensitivity and low diagnostic yield of RBUS with respect to VUR. However, the guideline emphasizes that early ultrasound can identify infectious parenchy...

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Value of Imaging Studies After a First Febrile Urinary Tract Infection in Young Children: Data From Italian Renal Infection Study 1

Cited by 100 publications

References 33 publications

Ultrasound as a Screening Test for Genitourinary Anomalies in Children With UTI

Ultrasound as a Screening Test for Genitourinary Anomalies in Children With UTI

First Febrile Urinary Tract Infection – Clinico-Biological Correlation with Imaging Studies - A Prospective Study

UTI and Watchful Waiting: The Courage to Do Nothing

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