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Pingree EW, Harper BD, Liu S, Neuman MI. National Trends in Voiding Cystourethrograms During Hospitalization for Young Infants With Urinary Tract Infections. Hosp Pediatr 2023; 13:904-911. [PMID: 37671444 DOI: 10.1542/hpeds.2022-007045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2023]
Abstract
OBJECTIVES The American Academy of Pediatrics published a guideline in 2011 recommending against the routine use of voiding cystourethrogram (VCUG) in infants aged 2 to 24 months with first febrile urinary tract infection (UTI); however, the rates of VCUG for infants aged <2 months are unknown. The objective of this study was to determine the trend in VCUG performance during index hospitalization among infants aged 0 to 2 months with UTI. METHODS This retrospective cohort study included infants aged birth to 2 months hospitalized with a UTI from 2008 to 2019 across 38 institutions in the Pediatric Health Information System. Outcome measures included recurrent UTI within 1 year, vesicoureteral reflux diagnosis within 1 year and antiurinary reflux procedure performed within 2 years. Trends over time were compared between preguideline (2008-2011) and postguideline periods (2012-2019) using piecewise mixed-effects logistic regression. RESULTS The odds of VCUG decreased by 21% per year in the preguideline period (adjusted odds ratio, 0.79; 95% confidence interval, 0.77-0.81; P < .001) versus 20% (adjusted odds ratio, 0.80; 95% confidence interval, 0.77-0.83; P < .001) in the postguideline period. The preguideline and postguideline difference was not statistically significant (P = .60). There was no difference in the postguideline odds of UTI within 1 year (P = .07), whereas the odds of vesicoureteral reflux diagnosis (P < .001) and antiurinary reflux procedure performance (P < .001) decreased. CONCLUSIONS VCUG performance during hospitalization has declined over the past decade among young infants hospitalized with UTI. Further work is needed to determine the optimal approach to imaging in these young infants.
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Affiliation(s)
| | | | - Shanshan Liu
- Biostatistics and Research Design Center, Institutional Centers for Clinical and Translational Research
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
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Current Management of Urinary Tract Infection and Vesicoureteral Reflux. Indian J Pediatr 2020; 87:625-632. [PMID: 31828601 DOI: 10.1007/s12098-019-03099-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 10/15/2019] [Indexed: 10/25/2022]
Abstract
Urinary tract infection (UTI) is defined as the growth of a significant number of microorganisms of a single species in the urine, in the presence of symptoms. Symptoms in young children are non-specific such as fever without focus; young infants may manifest with irritability, failure to thrive, jaundice, vomiting and diarrhea. Older children usually have symptoms of cystitis or pyelonephritis. Symptoms of cystitis are dysuria, frequency, new onset incontinence and malodorous urine while symptoms of pyelonephritis are high grade fever, flank pain and vomiting. Rapid urine testing by microscopy for pus cells, dipstick testing for leukocyte esterase and nitrite, and enhanced urinalysis are supportive tests. Urine culture samples should be collected with proper technique and results interpreted for significant growth accordingly. Antibiotic therapy for 7-14 d for complicated UTI and 3-4 d for uncomplicated UTI is adequate. Further evaluation is recommended clinically for bladder-bowel dysfunction and obvious anatomical defects and by imaging for vesicoureteral reflux (VUR), usually by micturating cystourethrography (MCU). Since MCU involves exposure to radiation and urethral catheterization, it is now reserved for children with parenchymal involvement or recurrent UTI. VUR is the backward flow of urine into one or both ureters. Clinical manifestations other than UTI include incidental diagnosis on antenatal ultrasonography. Reflux nephropathy, the renal scarring associated with VUR may manifest clinically as hypertension, proteinuria and renal failure. The management of VUR is primarily with antibiotic prophylaxis. Anatomical correction is indicated in case of breakthrough febrile UTI. No intervention has been shown to reduce renal scarring.
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Faura Morros A, Cuaresma González A, Hernández-Bou S, Trenchs Sainz de la Maza V, Camacho Diaz JA, Luaces Cubells C. Diagnostic efficiency of renal ultrasound after the first urine infection in infants. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.anpede.2018.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Faura Morros A, Cuaresma González A, Hernández-Bou S, Trenchs Sainz de la Maza V, Camacho Diaz JA, Luaces Cubells C. [Diagnostic efficiency of renal ultrasound after the first urine infection in infants]. An Pediatr (Barc) 2018; 90:232-236. [PMID: 30017745 DOI: 10.1016/j.anpedi.2018.06.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 06/06/2018] [Accepted: 06/12/2018] [Indexed: 10/28/2022] Open
Abstract
INTRODUCTION Several authors question the performance of systematic renal ultrasound after first urinary tract infection (UTI) in young children, given the high sensitivity of prenatal ultrasounds to detect major malformations and the low prevalence of clinical relevant findings. The aims of this study are to evaluate the yield of renal ultrasound performed after the first UTI in patients aged less than 2 years and to analyse potential risk factors (RF) of altered renal ultrasound. PATIENTS AND METHODS Retrospective study, including patients aged less than 2 years diagnosed with UTI in the Emergency Department between July 2013 and December 2014. Patients with an underlying nephro-urological pathology, previous UTIs and those without prenatal or post-infection renal ultrasound were excluded. Altered renal ultrasound was defined as the presence of dilated urinary tract or structural abnormalities. Potential RF analysed were: male, age less than 3 months, presence of fever and microorganism other than Escherichia coli. Univariate and multivariate logistic regression were performed. RESULTS A total of 306 patients were included. Altered renal ultrasound was found in 35 cases (11.4%; 95% CI 8.3-15.5): 24 (68.6%) urinary tract dilation, and 11 (31%) structural abnormalities. Among the cases with altered ultrasound, 68.6% were male, 51.4% were younger than 3 months, 74.3% were febrile, and 31.4% were caused by microorganisms other than E. coli, compared to 45% (P=.009), 31.7% (P=.021), 78.2% (P=.597) and 10% (P=.001) of cases with normal ultrasound. In the multivariate analysis, age less than 3 months (OR 2.1; 95% CI 1.0-4.3, P=.05) and microorganism other than E. coli (OR 3.8; 95% CI 1.7-8.7, P=.002) remained as RF. CONCLUSIONS The yield of renal ultrasound after the first UTI is low. Its indication should be individualised according to the presence of RF: age less than 3 months and microorganism other than E. coli.
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Affiliation(s)
- Anna Faura Morros
- Servicio de Urgencias de Pediatría, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, España
| | - Adriana Cuaresma González
- Servicio de Urgencias de Pediatría, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, España.
| | - Susanna Hernández-Bou
- Servicio de Urgencias de Pediatría, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, España
| | - Victoria Trenchs Sainz de la Maza
- Servicio de Urgencias de Pediatría, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, España; Influencia del entorno en el bienestar del niño y del adolescente, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Barcelona, España
| | | | - Carles Luaces Cubells
- Servicio de Urgencias de Pediatría, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, España; Influencia del entorno en el bienestar del niño y del adolescente, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Barcelona, España
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Vachvanichsanong P, Dissaneewate P, McNeil E. What Did We Find From Imaging Studies in Childhood Urinary Tract Infection and Which Studies Are Mandatory? Urology 2017; 111:176-182. [PMID: 28982546 DOI: 10.1016/j.urology.2017.09.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 09/09/2017] [Accepted: 09/19/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To evaluate the imaging results of childhood urinary tract infection (UTI) in our setting, and examine if it would be appropriate to apply the recent guideline changes regarding imaging studies as routine practice in Thailand. METHODS Medical records of children with UTI aged 0-15 years were reviewed, with focus on renal ultrasound (RUS), cystogram, and 99mTc dimercaptosuccinic acid (DMSA) renal scan results to determine congenital anomalies of the kidney and urinary tract (CAKUT) and renal damage. Mild CAKUT was defined as primary vesicoureteral reflux grades I-III or isolated hydronephrosis, and all other abnormalities were defined as severe CAKUT. RESULTS A total of 142 boys and 129 girls had at least 1 imaging study after UTI. Their median (interquartile range) age was 1.0 (0.5-2.7) year: 0.7 and 1.4 years for boys and girls, respectively (P = .006). A total of 262 children had an RUS performed, of which 99 (37.8%) were abnormal. Cystograms were performed in 221 children, from which 83 (37.6%) CAKUTs were detected, and 108 children had a DMSA performed, of which 53 (49.1%) were abnormal. Overall, CAKUTs were detected in 148 (54.6%) children, of which 43 were severe. RUS together with cystogram provided higher sensitivity (100% vs 88.9%) and specificity (53.8% vs 42.4%) to detect severe CAKUT than RUS together with DMSA. CONCLUSION A CAKUT was detected in more than half of the children with first UTI, with one-third having severe CAKUT. In our setting, RUS combined with cystogram is still the most reliable way to detect potentially harmful post-UTI problems, and the new western guidelines are not appropriate.
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Affiliation(s)
- Prayong Vachvanichsanong
- Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand.
| | - Pornsak Dissaneewate
- Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Edward McNeil
- Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
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Chang PW, Abidari JM, Shen MW, Greenhow TL, Bendel-Stenzel M, Roman HK, Biondi EA, Schroeder AR. Urinary Imaging Findings in Young Infants With Bacteremic Urinary Tract Infection. Hosp Pediatr 2016; 6:647-652. [PMID: 27707778 DOI: 10.1542/hpeds.2015-0229] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To describe renal ultrasound (RUS) and voiding cystourethrogram (VCUG) findings and determine predictors of abnormal imaging in young infants with bacteremic urinary tract infection (UTI). METHODS We used retrospective data from a multicenter sample of infants younger than 3 months with bacteremic UTI, defined as the same pathogenic organism in blood and urine. Infants were excluded if they had any major comorbidities, known urologic abnormalities at time of presentation, required intensive unit care, or had no imaging performed. Imaging results as stated in the radiology reports were categorized by a pediatric urologist. RESULTS Of the 276 infants, 19 were excluded. Of the remaining 257 infants, 254 underwent a RUS and 224 underwent a VCUG. Fifty-five percent had ≥1 RUS abnormalities. Thirty-four percent had ≥1 VCUG abnormalities, including vesicoureteral reflux (VUR, 27%), duplication (1.3%), and infravesicular abnormality (0.9%). Age <1 month, male sex, and non-Escherichia coli organism predicted an abnormal RUS, but only non-E coli organism predicted an abnormal VCUG. Seventeen of 96 infants (17.7%) with a normal RUS had an abnormal VCUG: 15 with VUR (Grade I-III = 13, Grade IV = 2), 2 with elevated postvoid residual, and 1 with infravesical abnormality. CONCLUSIONS Although RUS and VCUG abnormalities were common in this cohort, the frequency and severity were similar to previous studies of infants with UTIs in general. Our findings do not support special consideration of bacteremia in imaging decisions for otherwise well-appearing young infants with UTI.
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Affiliation(s)
- Pearl W Chang
- Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington; .,Department of Pediatrics, Kaiser Permanente Northern California, Oakland, California
| | | | - Mark W Shen
- Department of Pediatrics, Dell Children's Medical Center, Austin, Texas
| | - Tara L Greenhow
- Division of Infectious Diseases, Department of Pediatrics, Kaiser Permanente Northern California, San Francisco, California
| | - Michael Bendel-Stenzel
- Department of Pediatrics, Children's Hospital and Clinics of Minnesota, Minneapolis, Minnesota
| | - Heidi K Roman
- Department of Pediatrics, University of Texas Southwestern, Dallas, Texas
| | - Eric A Biondi
- Department of Pediatrics, University of Rochester, Rochester, New York; and
| | - Alan R Schroeder
- Pediatrics, Santa Clara Valley Medical Center, San Jose, California.,Department of Pediatrics, Stanford University School of Medicine, Stanford, California
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Tasian GE. Commentary to 'Renal damage detected by DMSA despite normal renal ultrasound in children with febrile UTI'. J Pediatr Urol 2015; 11:127-8. [PMID: 25837704 DOI: 10.1016/j.jpurol.2015.01.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 01/28/2015] [Indexed: 11/19/2022]
Affiliation(s)
- Gregory E Tasian
- Children's Hospital of Philadelphia, Urology, 34th Street and Civic Center Blvd, Wood Center, 3rd Floor Urology, Philadelphia, PA, 19104, USA.
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Canning DA. Re: Ultrasound as a Screening Test for Genitourinary Anomalies in Children with UTI. J Urol 2015; 193:300-1. [DOI: 10.1016/j.juro.2014.10.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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