A nurse led education and direct access service for the management of urinary tract infections in children: prospective controlled trial

Point-of-care tests for pediatric urinary tract infections in general practice: a diagnostic accuracy study

BACKGROUND

Early diagnosis of pediatrics urinary tract infections in the outpatient settings is challenging but essential to prevent hospitalization and kidney damage.

OBJECTIVE

We aimed to evaluate the diagnostic test accuracy of a selection of point-of-care tests for pediatric urinary tract infections in general practice.

METHODS

A prospective cross-sectional study in 26 general practices in Flanders, Belgium (clinicaltrials.gov, NCT03835104). Urine was sampled systematically from children between 3 months to 18 years presenting with an acute illness of maximum 10 days. Samples were analyzed at the central laboratory with a routine dipstick test, the Utriplex test, the Uriscreen test and the Rapidbac as index tests, and with urine culture showing more than 105 colony-forming units per milliliter of one pathogen as reference standard. For each test, we calculated sensitivity, specificity, positive and negative likelihood ratios, and predictive values with 95% confidence intervals.

RESULTS

Three-hundred urine samples were available for analysis of which 30 samples were culture positive (10%). Sensitivities and specificities were 32% (95% CI 16%-52%) and 86% (95% CI 82%-90%) for the dipstick test, 21% (95% CI 8%-40%) and 94% (95% CI 91%-97%) for the Utriplex test, 40% (95% CI 16%-68%) and 83% (95% CI 75%-88%) for the Rapidbac test, and 67% (95% CI 38%-88%) with 69% (95% CI 60%-76%) for the Uriscreen test.

CONCLUSION

All 4 point-of-care tests were suboptimal for use in the broad range of children presenting with acute illnesses to general practice. General practitioners need novel methods for obtaining reliable urine samples during the time of the consultation, especially for children not yet toilet-trained.

Clinical Features for the Diagnosis of Pediatric Urinary Tract Infections: Systematic Review and Meta-Analysis

PURPOSE

Accurate diagnosis of urinary tract infection in children is essential because children left untreated can experience permanent renal injury. We aimed to assess the diagnostic value of clinical features of pediatric urinary tract infection.

METHODS

We performed a systematic review and meta-analysis of diagnostic test accuracy studies in ambulatory care. We searched the PubMed, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Health Technology Assessment, and Database of Abstracts of Reviews of Effects databases from inception to January 27, 2020 for studies reporting 2 × 2 diagnostic accuracy data for clinical features compared with urine culture in children aged <18 years. For each clinical feature, we calculated likelihood ratios and posttest probabilities of urinary tract infection. To estimate summary parameters, we conducted a bivariate random effects meta-analysis and hierarchical summary receiver operating characteristic analysis.

RESULTS

A total of 35 studies (N = 78,427 patients) of moderate to high quality were included, providing information on 58 clinical features and 6 prediction rules. Only circumcision (negative likelihood ratio [LR-] 0.24; 95% CI, 0.08-0.72; n = 8), stridor (LR- 0.20; 95% CI, 0.05-0.81; n = 1), and diaper rash (LR- 0.13; 95% CI, 0.02-0.92; n = 1) were useful for ruling out urinary tract infection. Body temperature or fever duration showed limited diagnostic value (area under the receiver operating characteristic curve 0.61; 95% CI, 0.47-0.73; n = 16). The Diagnosis of Urinary Tract Infection in Young Children score, Gorelick Scale score, and UTIcalc (https://uticalc.pitt.edu) might be useful to identify children eligible for urine sampling.

CONCLUSIONS

Few clinical signs and symptoms are useful for diagnosing or ruling out urinary tract infection in children. Clinical prediction rules might be more accurate; however, they should be validated externally. Physicians should not restrict urine sampling to children with unexplained fever or other features suggestive of urinary tract infection.

What's the catch? Urine sample collection from young pre-continent children: a qualitative study in primary care

Background

Urinary tract infections (UTIs) are common in young pre-continent children, but collecting urine samples is challenging. Collection methods all have limitations and international guidelines have conflicting recommendations. Choice of method must balance time, resources, invasiveness, reliability, and contamination. Evidence from primary care clinicians is limited regarding barriers and enablers to sample collection, and what factors inform the choice and use of different sample collection methods.

Aim

To understand the barriers and enablers to collecting urine samples from young pre-continent children in primary care.

Design & setting

An exploratory qualitative study performed in primary care in Australia.

Method

Semi-structured interviews explored the topic of collecting a urine sample from a child aged 6 months who presented with a fever. The interviews were undertaken with 21 GPs and four practice nurses (PNs) until data saturation was reached. Interviews were audiorecorded, transcribed verbatim, coded, and underwent content and thematic analysis.

Results

Five main themes emerged including: the clinician’s knowledge and expertise; patient characteristics; parent or carer’s understanding and motivation; the collection process itself; and likely outcome of the chosen method. Non-invasive methods were strongly favoured; although, clean catch was considered time-consuming and urine bags were known to be often contaminated. Invasive methods (for example, catheterisation or suprapubic aspiration [SPA]) were rarely performed outside of remote settings. Key barriers included time and space constraints in clinics, and key enablers included parental motivation, education handouts, and voiding stimulation methods.

Conclusion

This study has identified key barriers and enablers to inform education, policy, and future research for urine sample collection from pre-continent children in primary care. Guideline recommendations must consider the primary care context to ensure they are relevant and suited to real-world practice.

Long-term outcomes of urinary tract infection (UTI) in Childhood (LUCI): protocol for an electronic record-linked cohort study

INTRODUCTION

Current guidelines advise the prompt diagnosis and treatment of urinary tract infection (UTI) in children to improve both short and longer term outcomes. However, the risk of long-term complications following childhood UTI is unclear.UTI is relatively common but difficult to diagnose in children as symptoms are non-specific. Diagnosis requires a urine sample, but sampling is difficult and infrequent, and it is not clear if sampling should be given greater priority in primary care. The LUCI study will assess the short, medium and longer term outcomes of childhood UTI associated with routine and systematic sampling practices.

METHODS AND ANALYSIS

Two data sets will be established. The first will consist of routinely collected data (hospital, general practice (GP), microbiology) from children born and resident in Wales, linked via the Secure Anonymised Information Linkage (SAIL) Databank (an 'e-cohort'). Urine sampling in this data set reflects normal practice 'routine sampling'. Outcomes (including renal scarring, hypertension, end-stage renal failure, hospital admissions, GP consultations, antibiotic prescriptions) for children with at least one UTI confirmed with microbiological culture (mcUTI) or no mcUTI before the age of 5 will be compared.The second will combine data from two prospective observational studies ('DUTY' and 'EURICA') employing systematic urine sampling for children presenting to primary care with acute, undifferentiated illness, linked to routine data via SAIL (Wales) and NHS Digital (England). Outcomes (as above, plus features of mcUTI) for children with an mcUTI in this data set, identified through systematic urine sampling, will be compared with those with an mcUTI identified through routine urine sampling (data set 1).

ETHICS AND DISSEMINATION

The study protocol has been approved by NHS Wales Research Ethics Committee and the Health Research Authority's Confidentiality Advisory Group. Methods of innovative study design and findings will be disseminated through peer-review journals and conferences. Results will be of interest to clinical and policy stakeholders in the UK.

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

BACKGROUND

It 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.

OBJECTIVES

To 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.

DESIGN

Multicentre, prospective diagnostic cohort study.

SETTING AND PARTICIPANTS

Children < 5 years old presenting to primary care with an acute illness and/or new urinary symptoms.

METHODS

One 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 ≥ 10(5) colony-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'.

RESULTS

A 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.

CONCLUSIONS

Clinicians 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.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Nappy pad urine samples for investigation and treatment of UTI in young children: the 'DUTY' prospective diagnostic cohort study

BACKGROUND

The added diagnostic utility of nappy pad urine samples and the proportion that are contaminated is unknown.

AIM

To develop a clinical prediction rule for the diagnosis of urinary tract infection (UTI) based on sampling using the nappy pad method.

DESIGN AND SETTING

Acutely unwell children <5 years presenting to 233 UK primary care sites.

METHOD

Logistic regression to identify independent associations of symptoms, signs, and urine dipstick test results with UTI; diagnostic utility quantified as area under the receiver operator curves (AUROC). Nappy pad rule characteristics, AUROC, and contamination, compared with findings from clean-catch samples.

RESULTS

Nappy pad samples were obtained from 3205 children (82% aged <2 years; 48% female), culture results were available for 2277 (71.0%) and 30 (1.3%) had a UTI on culture. Female sex, smelly urine, darker urine, and the absence of nappy rash were independently associated with a UTI, with an internally-validated, coefficient model AUROC of 0.81 (0.87 for clean-catch), which increased to 0.87 (0.90 for clean-catch) with the addition of dipstick results. GPs' 'working diagnosis' had an AUROC 0.63 (95% confidence intervals [CI] = 0.53 to 0.72). A total of 12.2% of nappy pad and 1.8% of clean-catch samples were 'frankly contaminated' (risk ratio 6.66; 95% CI = 4.95 to 8.96; P<0.001).

CONCLUSION

Nappy pad urine culture results, with features that can be reported by parents and dipstick tests, can be clinically useful, but are less accurate and more often contaminated compared with clean-catch urine culture.

Childhood urinary tract infection in primary care: a prospective observational study of prevalence, diagnosis, treatment, and recovery

BACKGROUND

The prevalence of targeted and serendipitous treatment for, and associated recovery from, urinary tract infection (UTI) in pre-school children is unknown.

AIM

To determine the frequency and suspicion of UTI in children who are acutely ill, along with details of antibiotic prescribing, its appropriateness, and whether that appropriateness impacted on symptom improvement and recovery.

DESIGN AND SETTING

Prospective observational cohort study in primary care sites in urban and rural areas in England and Wales.

METHOD

Systematic urine sampling from children aged <5 years presenting in primary care with acute illness with culture in NHS laboratories.

RESULTS

Of 6079 children's urine samples, 339 (5.6%) met laboratory criteria for UTI and 162 (47.9%) were prescribed antibiotics at the initial consultation. In total, 576/7101 (8.1%) children were suspected of having a UTI prior to urine sampling, including 107 of the 338 with a UTI (clinician sensitivity 31.7%). Children with a laboratory-diagnosed UTI were more likely to be prescribed antibiotics when UTI was clinically suspected than when it was not (86.0% versus 30.3%, P<0.001). Of 231 children with unsuspected UTI, 70 (30.3%) received serendipitous antibiotics (that is, antibiotics prescribed for a different reason). Overall, 176 (52.1%) children with confirmed UTI did not receive any initial antibiotic. Organism sensitivity to the prescribed antibiotic was higher when UTI was suspected than when treated serendipitously (77.1% versus 26.0%; P<0.001). Children with UTI prescribed appropriate antibiotics at the initial consultation improved a little sooner than those with a UTI who were not prescribed appropriate antibiotics initially (3.5 days versus 4.0 days; P = 0.005).

CONCLUSION

Over half of children with UTI on culture were not prescribed antibiotics at first presentation. Serendipitous UTI treatment was relatively common, but often inappropriate to the organism's sensitivity. Methods for improved targeting of antibiotic treatment in children who are acutely unwell are urgently needed.

Improving the Diagnosis and Treatment of Urinary Tract Infection in Young Children in Primary Care: Results from the DUTY Prospective Diagnostic Cohort Study

PURPOSE

Up to 50% of urinary tract infections (UTIs) in young children are missed in primary care. Urine culture is essential for diagnosis, but urine collection is often difficult. Our aim was to derive and internally validate a 2-step clinical rule using (1) symptoms and signs to select children for urine collection; and (2) symptoms, signs, and dipstick testing to guide antibiotic treatment.

METHODS

We recruited acutely unwell children aged under 5 years from 233 primary care sites across England and Wales. Index tests were parent-reported symptoms, clinician-reported signs, urine dipstick results, and clinician opinion of UTI likelihood (clinical diagnosis before dipstick and culture). The reference standard was microbiologically confirmed UTI cultured from a clean-catch urine sample. We calculated sensitivity, specificity, and area under the receiver operator characteristic (AUROC) curve of coefficient-based (graded severity) and points-based (dichotomized) symptom/sign logistic regression models, and we then internally validated the AUROC using bootstrapping.

RESULTS

Three thousand thirty-six children provided urine samples, and culture results were available for 2,740 (90%). Of these results, 60 (2.2%) were positive: the clinical diagnosis was 46.6% sensitive, with an AUROC of 0.77. Previous UTI, increasing pain/crying on passing urine, increasingly smelly urine, absence of severe cough, increasing clinician impression of severe illness, abdominal tenderness on examination, and normal findings on ear examination were associated with UTI. The validated coefficient- and points-based model AUROCs were 0.87 and 0.86, respectively, increasing to 0.90 and 0.90, respectively, by adding dipstick nitrites, leukocytes, and blood.

CONCLUSIONS

A clinical rule based on symptoms and signs is superior to clinician diagnosis and performs well for identifying young children for noninvasive urine sampling. Dipstick results add further diagnostic value for empiric antibiotic treatment.

Ureteroneocystostomy in primary vesicoureteral reflux: critical retrospective analysis of factors affecting the postoperative urinary tract infection rates

INTRODUCTION

To determine the parameters affecting the outcome of ureteroneocystostomy (UNC) procedure for vesicoureteral reflux (VUR).

MATERIALS AND METHODS

Data of 398 patients who underwent UNC procedure from 2001 to 2012 were analyzed retrospectively. Different UNC techniques were used according to laterality of reflux and ureteral orifice configuration. Effects of several parameters on outcome were examined. Disappearance of reflux on control VCUG or absence of any kind of UTI/symptoms in patients without control VCUG was considered as clinical improvement.

RESULTS

Mean age at operation was 59.2 ± 39.8 months and follow-up was 25.6 ± 23.3 months. Grade of VUR was 1-2, 3 and 4-5 in 17, 79, 302 patients, respectively. Male to female ratio was 163/235. UNC was performed bilaterally in 235 patients and intravesical approach was used in 373 patients. The frequency of voiding dysfunction, scar on preoperative DMSA, breakthrough infection and previous surgery was 28.4%, 70.7%, 49.3% and 22.4%, respectively. Twelve patients (8.9%) with postoperative contralateral reflux were excluded from the analysis. Overall clinical improvement rate for UNC was 92%. Gender, age at diagnosis and operation, laterality and grade of reflux, mode of presentation, breakthrough infections (BTI) under antibiotic prophylaxis, presence of voiding dysfunction and renal scar, and operation technique did not affect the surgical outcome. However, the clinical improvement rate was lower in patients with a history of previous endoscopic intervention (83.9% vs. 94%). Postoperative UTI rate was 27.2% and factors affecting the occurrence of postoperative UTI were previous failed endoscopic injection on univariate analysis and gender, preoperative BTI, postoperative VUR state, voiding dysfunction on multivariate analysis. Surgery related complication rate was 2% (8/398). These were all low grade complications (blood transfusion in 1, hematoma under incision in 3 and prolonged hospitalization secondary to UTI in 4 patients). In long term, 12 patients are under nephrologic follow-up because of hypertension in 5, increased serum creatinine in 5, proteinuria in 1 and hematuria in 1 patient and all these patients had preoperative scarred kidneys.

CONCLUSIONS

Despite its invasive nature, UNC has a very high success rate with a negligible percent of complications. In our cohort, the only factor that negatively affected the clinical improvement rate was the history of previous antireflux interventions where the predictive factors for postoperative UTI were previous failed endoscopic injection, female gender, preoperative BTI, persistent VUR and voiding dysfunction.

Guidelines to identify abnormalities after childhood urinary tract infections: a prospective audit

OBJECTIVE

To compare the childhood urinary tract infection (UTI) guidelines from the Royal College of Physicians (RCP) in 1991 and from National Institute of Health and Care Excellence (NICE) (CG54) in 2007 by measuring their efficiency at detecting urinary tract abnormalities.

DESIGN

Children with UTIs within the Newcastle Primary Care Trust (population 70,800 children) were referred and imaged according to the RCP guidelines during 2008, and these were compared to the activity that would have been undertaken if we had implemented the CG54 guidelines, including following them through 2011 to identify those with recurrent UTIs.

MAIN OUTCOME MEASURES

The numbers of children imaged, the imaging burden and efficiency, and urinary tract abnormalities detected by each guideline.

RESULTS

Fewer children would have been imaged by CG54 than RCP (150 vs 427), but its sensitivity was lower, at 44% for detecting scarring, 10% for identifying vesicoureteric reflux and 40% for other abnormalities. Overall, it would have only detected one-quarter of the abnormal cases (8 vs 32) and would have missed five of nine children with scarring, including three with multiple lesions and one with renal impairment. Imposing an age restriction of <8 years to the RCP guidelines would reduce its screening rate by 20% and still detect 90% of the abnormalities.

INTERPRETATION

The CG54 guidelines do not alter the imaging efficiency compared to the RCP guidelines, but they are considerably less sensitive.

Does prompt treatment of urinary tract infection in preschool children prevent renal scarring: mixed retrospective and prospective audits

OBJECTIVE

To test whether active management of urinary tract infections (UTI) in young children by general practitioners can reduce kidney scarring rates.

DESIGN

A comparison of two audits in Newcastle, of children aged <8 years, presenting with UTIs ; a retrospective audit of conventional management during 1992-1995 (1990s) versus a prospective audit of direct access management during 2004-2011 (2000s).

MAIN OUTCOME MEASURES

Kidney scarring rates, and their relationship with time-to-treat.

RESULTS

Children with a first UTI in the 2000s compared to those in the 1990s, were referred younger, were half as likely to have a renal scar (girls OR 0.47, 95% CI 0.29 to 0.76; boys 0.35, 0.16 to 0.81), and were about 12 times more likely to have vesicoureteric reflux without scarring (girls 11.9, 4.3 to 33.5; boys 14.4, 4.3 to 47.6). In the 2000s, general practitioners treated about half the children at first consultation. Children who were treated within 3 days of their symptoms starting were one-third as likely to scar as those whose symptoms lasted longer (0.33, 0.12 to 0.72).

INTERPRETATION

Most kidney defects seen in children after UTIs, are acquired scars, and in Newcastle, active management in primary care has halved this rate.

Prevalence of urinary tract infection in acutely unwell children in general practice: a prospective study with systematic urine sampling

BACKGROUND

Urinary tract infection (UTI) in children may be associated with long-term complications that could be prevented by prompt treatment.

AIM

To determine the prevalence of UTI in acutely ill children ≤ 5 years presenting in general practice and to explore patterns of presenting symptoms and urine sampling strategies.

DESIGN AND SETTING

Prospective observational study with systematic urine sampling, in general practices in Wales, UK.

METHOD

In total, 1003 children were recruited from 13 general practices between March 2008 and July 2010. The prevalence of UTI was determined and multivariable analysis performed to determine the probability of UTI.

RESULT

Out of 597 (60.0%) children who provided urine samples within 2 days, the prevalence of UTI was 5.9% (95% confidence interval [CI] = 4.3% to 8.0%) overall, 7.3% in those < 3 years and 3.2% in 3-5 year olds. Neither a history of fever nor the absence of an alternative source of infection was associated with UTI (P = 0.64; P = 0.69, respectively). The probability of UTI in children aged ≥3 years without increased urinary frequency or dysuria was 2%. The probability of UTI was ≥5% in all other groups. Urine sampling based purely on GP suspicion would have missed 80% of UTIs, while a sampling strategy based on current guidelines would have missed 50%.

CONCLUSION

Approximately 6% of acutely unwell children presenting to UK general practice met the criteria for a laboratory diagnosis of UTI. This higher than previously recognised prior probability of UTI warrants raised awareness of the condition and suggests clinicians should lower their threshold for urine sampling in young children. The absence of fever or presence of an alternative source of infection, as emphasised in current guidelines, may not rule out UTI in young children with adequate certainty.

The diagnosis of urinary tract infections in young children (DUTY): protocol for a diagnostic and prospective observational study to derive and validate a clinical algorithm for the diagnosis of UTI in children presenting to primary care with an acute illness

Background

Urinary tract infection (UTI) is common in children, and may cause serious illness and recurrent symptoms. However, obtaining a urine sample from young children in primary care is challenging and not feasible for large numbers. Evidence regarding the predictive value of symptoms, signs and urinalysis for UTI in young children is urgently needed to help primary care clinicians better identify children who should be investigated for UTI. This paper describes the protocol for the Diagnosis of Urinary Tract infection in Young children (DUTY) study. The overall study aim is to derive and validate a cost-effective clinical algorithm for the diagnosis of UTI in children presenting to primary care acutely unwell.

Methods/design

DUTY is a multicentre, diagnostic and prospective observational study aiming to recruit at least 7,000 children aged before their fifth birthday, being assessed in primary care for any acute, non-traumatic, illness of ≤ 28 days duration. Urine samples will be obtained from eligible consented children, and data collected on medical history and presenting symptoms and signs. Urine samples will be dipstick tested in general practice and sent for microbiological analysis. All children with culture positive urines and a random sample of children with urine culture results in other, non-positive categories will be followed up to record symptom duration and healthcare resource use. A diagnostic algorithm will be constructed and validated and an economic evaluation conducted.

The primary outcome will be a validated diagnostic algorithm using a reference standard of a pure/predominant growth of at least >10³, but usually >10⁵ CFU/mL of one, but no more than two uropathogens.

We will use logistic regression to identify the clinical predictors (i.e. demographic, medical history, presenting signs and symptoms and urine dipstick analysis results) most strongly associated with a positive urine culture result. We will then use economic evaluation to compare the cost effectiveness of the candidate prediction rules.

Discussion

This study will provide novel, clinically important information on the diagnostic features of childhood UTI and the cost effectiveness of a validated prediction rule, to help primary care clinicians improve the efficiency of their diagnostic strategy for UTI in young children.

Natural history of bilateral mild isolated antenatal hydronephrosis conservatively managed

BACKGROUND

The purpose of this study was to assess the prevalence and outcome of newborns with bilateral mild isolated antenatal hydronephrosis managed with neither antibiotic prophylaxis nor voiding cystourethrography (VCUG).

METHODS

Inclusion criteria were ultrasonographic evidence of an anterior-posterior pelvic diameter (APPD) of 5-15 mm at the third trimester of gestation and on the first postnatal ultrasound sonogram. Exclusion criteria were an APPD >15 mm, calyectasis, hydroureteronephrosis, or renal or bladder abnormalities. Ultrasound follow-up was performed. Parents were familiarized with the signs of urinary tract infection (UTI). If UTI was confirmed, VCUG was performed. The outcome was assessed as intrauterine resolution of hydronephrosis, total or partial resolution, stability, or progression.

RESULTS

Hydronephrosis was bilateral in 98 of the 236 newborns (196 hydronephrotic kidneys) with mild isolated antenatal hydronephrosis enrolled in this study. Nine patients had UTI, and none showed reflux. After a mean follow-up of 15 months, 74 kidneys showed intrauterine resolution (38%), 82 (42%) showed total resolution, 13 showed partial resolution, 24 were stable, and 3 showed progression. Bilateral cases represented 42% of mild isolated antenatal hydronephrosis. During the first year of life, 80% of the kidneys showed total hydronephrosis resolution, 9% of patients had UTI, and none of the patients showed reflux.

CONCLUSIONS

Antibiotic prophylaxis and VCUG are not mandatory in newborns with bilateral mild isolated antenatal hydronephrosis, but clinical and ultrasound follow-up are recommended during the first year of life.

Short-term outcome of mild isolated antenatal hydronephrosis conservatively managed

OBJECTIVES

To assess the outcome of newborns with mild isolated antenatal hydronephrosis (MIAHN) managed with neither antibiotic prophylaxis nor voiding cystourethrography (VCUG).

INCLUSION CRITERIA

anterior-posterior pelvic diameter 5-15 mm at third trimester of gestation, confirmed by first postnatal ultrasound.

EXCLUSION CRITERIA

pelvic diameter > 15 mm, calyectasis, hydroureteronephrosis, renal or bladder abnormalities. Clinical and ultrasound follow-up was performed. Parents were familiarized with urinary tract infection (UTI) signs. If UTI was confirmed, VCUG was performed. Hydronephrosis outcome was assessed as intrauterine resolution, total or partial resolution, stability or progression.

RESULTS

MIAHN was detected in 193 newborns (109 unilateral, 84 bilateral; 277 renal units); 23 (12%) had UTI and 2 of them showed low-grade reflux. After a mean follow-up of 15 months, 91 renal units showed intrauterine resolution (33%), 111 (40%) total resolution, 20 (7%) partial resolution, 52 (19%) stability and 3 (1%) progression.

CONCLUSION

Total resolution of hydronephrosis was observed in 73% of renal units during the first year. Routine antibiotic prophylaxis and VCUG might not be necessary in all infants with MIAHN, clinical and ultrasound follow-up being advisable during the first year of life.

Effectiveness of educational interventions to raise men's awareness of bladder and bowel health

BACKGROUND

Urinary incontinence is a common health problem with significant medical, psychological and economic burdens. Health education is capable of improving perceptions about and attitudes towards incontinence in turn encouraging them to seek help.

AIM

The aim of the present study was to determine the effectiveness of educational interventions at raising men's awareness of bladder and bowel health.

INCLUSION CRITERIA

Types of participants. Adult and adolescent men (age 12 years and over) and it was anticipated that some interventions/promotions may be directed at family members or carers of, and health professionals caring for, adult men and therefore these would also be considered for inclusion. Types of intervention. Any intervention, program or action that provided information, or attempted to raise awareness of men's bladder and bowel health. Type of outcome. Any measure defined by included studies such as: bladder and bowel management and treatment, increased knowledge of bladder and bowel health and number of attendees at promotion. Type of studies. Concurrent controls, such as: systematic reviews of concurrently controlled trials, meta-analysis, randomised controlled trials, controlled clinical trials, interrupted time series and controlled before after designs and observational design (cohort, case-control). Search strategy. A search for published and unpublished studies in the English language was undertaken restricted by a publication date of 10 years prior, with the exception of a review of seminal papers before this time.

METHODOLOGICAL QUALITY

Each study was appraised independently by two reviewers using the standard Joanna Briggs Institute instruments.

DATA COLLECTION AND ANALYSIS

Information was extracted from studies meeting quality criteria using the standard Joanna Briggs Institute tools. For two studies with similar population types, interventions and outcomes quantitative results were combined into a meta-analysis using Revman 5.0 software. However, the majority of studies were heterogenous and results are presented in a narrative form.

RESULTS

With the exception of instruction for pelvic floor muscle exercises for men after prostatectomy, little quantitative research has been performed that establishes the effectiveness of interventions on men's awareness of bladder and bowel health. While numerous interventions have been trialled on mixed gender populations, and these trials suggest that the interventions would be effective, their effectiveness on the male component cannot be definitively established.

CONCLUSION

There is little quantitative evidence for the effectiveness of interventions to improve men's awareness of bladder and bowel health therefore few recommendations can be made. Well-designed controlled trials using male sample populations only are needed.

Genetic susceptibility to renal scar formation after urinary tract infection: a systematic review and meta-analysis of candidate gene polymorphisms

Identifying patients who may develop renal scarring after urinary tract infections (UTI) remains challenging, as clinical determinants explain only a portion of individual risk. An additional factor that likely affects risk is individual genetic variability. We searched for peer-reviewed articles from 1980 to December 2009 in electronic databases that reported results showing an association between gene polymorphims and renal scaring after UTI. Two independent researchers screened articles using predetermined criteria. Studies were assessed for methodological quality using an aggregate scoring system. The 18 studies ultimately included in the review had investigated 16 polymorphisms in nine genes in association with renal scarring formation after UTI. Based on the predetermined criteria for assessing the quality of the studies, 12 studies (67%) were identified as being of poor quality design. A meta-analysis of cumulative studies showed on association between renal scarring formation after UTI and the angiotensin converting enzyme insertion/deletion polymorphism [ACE I/D; recessive model for D allele; odds ratio (OR) 1.73, 95% confidence interval (CI) 1.09-2.74, P = 0.02] or transforming growth factor (TGF)-β1 c.-509 T > C polymorphism (dominant model for T allele; OR 2.24, 95% CI 1.34-3.76, P = 0.002). However, heterogeneity among studies was large, indicating a strong difference that cannot only be explained by differences in study design. The studies reviewed in this article support a modest involvement of the vasomotor and inflammatory genes in the development of renal scarring after UTIs. This review also shows that only few possible candidate genes have been investigated for an association with renal scarring, raising the hypothesis that some gene polymorphisms may exert their effects through an interaction with as yet uninvestigated factors that may be related to geographic and/or socio-economic differences.

Vesicoureteral reflux in children with suspected and proven urinary tract infection

The aim of this study was to estimate the prevalence of vesicoureteral reflux (VUR) and clinically significant ultrasonography (US) abnormalities in a large group of children with proven and suspected urinary tract infection (UTI). The medical reports on renal US and voiding cystouretrographies (VCUG) of 2,036 children were reviewed. Renal US was performed on all children and VCUG on 1,185 children (58%). Based on the urine culture data, the UTI diagnoses were classified into five reliability classes (proven, likely, unlikely, false and no microbial data). The UTI diagnose was considered proven in 583/2036 (28.6%) and false in 145 (7.1%) cases. The prevalence of VUR was similar among those with proven and false UTI [37.4 vs. 34.8%; relative risk (RR) 1.08, 95% confidence intervals (95% CI) 0.7-1.7, P = 0.75] and decreased with increasing age (P = 0.001). Clinically significant US abnormalities occurred in 87/583 (14.9%) cases with proven UTI and significantly less often (11/145, 7.6%) in the false UTI class (RR 1.96, 95% CI 1.1-3.6, P = 0.02). Our finding supports the claim that VUR is not significantly associated to UTI and that its occurrence among children even without UTI is significantly higher than traditional estimates. This challenges the recommendations of routine VCUG after UTI.

Vesicoureteric reflux is not a benign condition

Renal parenchymal defects may be congenital, usually associated with dilated vesicoureteric reflux (VUR), or they may appear in previously normal kidneys and be caused by reflux nephropathy due to VUR combined with urinary tract infection (UTI). A piglet model defined that the 70% of children with VUR and vulnerable pyramids would scar rapidly with their first UTI. Because most defects are present at first imaging after a UTI, and from the lack of benefit from apparently reasonable clinical interventions, many now believe that most defects are congenital, their association with VUR being a shared dysplasia rather than causal. Consequently, guidelines now argue for less assiduous management. These conclusions ignore adult human transplant evidence, adult pig studies, and clinical anecdotes, which indicate that scars may develop in infant kidneys quicker than urine culture can confirm the diagnosis, and that reflux nephropathy has no age limit. Its rarity over 4 years suggests that most vulnerable children develop scars before then, despite all medical efforts. I argue that preventing such scarring will require better diagnosis of infant UTI, quicker treatment, reliable imaging of scars and VUR, and subsequent protection until VUR resolves. To make a difference, we need more assiduous management, not less, and cannot afford to consider VUR to be a benign condition.

Reflux Nephropathy in Kidney Transplants, Demonstrated by Dimercaptosuccinic Acid Scanning

BACKGROUND

This study determines why kidney transplants develop new focal defects.

METHODS

Thirty children at a U.K. pediatric nephrology department receiving kidney transplants had early and late dimercaptosuccinic acid (DMSA) scans to detect acquired focal defects, and their presence correlated with possible risk factors. Associations between clinical events and focal DMSA lesions appearing in grafts were measured.

RESULTS

Of the 30 early DMSA scans (within 2 weeks of function), one child with a thrombosed polar artery had a focal defect. On rescanning later, 11 (37%) had acquired segmental defects; five were multiple, and their glomerular filtration rates were 20 ml/min/1.73 m lower (95% CI 7-34). Histology in one case showed pyelonephritic scarring. Reflux into the transplant ureter occurred in 19/27 (70%) of children tested (by radiological or indirect radionuclide cystography). Nine of 13 children (69%) who had a combination of reflux and a urine infection had acquired scars, whereas only 1/14 (7%) did without this combination (P = 0.001). Scarring was not associated with the age or sex of the donor or recipient, rejection episodes, renal biopsy, or drug-induced nephrotoxicity.

CONCLUSION

Kidney transplants are at high risk of developing segmental pyelonephritic scars if infected urine refluxes into the graft, either early through a transanastomotic stent or later from vesicoureteric reflux. These scars may reduce the renal function and are readily seen on DMSA, but not ultrasound scans. Consideration should be given to more effective antireflux surgery for transplants, with subsequent testing for reflux, urinary antibiotic prophylaxis, and prompt treatment of urine infections.