ORLANDO – The proportion of infants and young children who had voiding cystourethrograms after an emergency department visit for an initial febrile urinary tract infection decreased by more than 50% after the 2011 American Academy of Pediatrics guidelines advised a VCUG only if indicated by sonographic findings, based on a review of cases.
However, ultrasound findings and voiding cystourethrogram (VCUG) positivity were not correlated in the series of patients studied, Dr. Andrew J. Kirsch reported at the annual meeting of the American Urological Association.
The findings raise concerns that cases of vesicoureteral reflux are being missed and call into question whether the AAP recommendation to use sonographic findings as the determinant for obtaining additional imaging should be uniformly applied after an initial febrile UTI in children aged 2 months to 2 years, said Dr. Kirsch, a pediatric urologist with Children’s Healthcare of Atlanta. Those presenting to the ED may be more ill and may be more likely to have underlying vesicoureteral reflux or an anatomic abnormality.
While most clinicians agree with the majority of action statements in the AAP guidelines, the diagnostic imaging recommendations are widely debated. Several recent studies have demonstrated a lack of correlation between renal and bladder ultrasound results and VCUG positivity. Further, the recommendation to limit VCUGs was based on studies that showed no benefit with antibiotic prophylaxis in children with vesicoureteral reflux. Recent large, randomized controlled trials, however, have shown benefits of diagnosing and treating vesicoureteral reflux, he said.
For the case review study reported by Dr. Kirsch, two cohorts were evaluated at urgent care centers and EDs in a pediatric health care system during the 6-month periods before and after the guidelines were implemented. Children with a history of vesicoureteral reflux or VCUG, prior febrile urinary tract infection, or undocumented urine culture of afebrile UTIs were excluded from the analysis.
Of 178 children aged 2 months to 2 years who were seen in the ED between January and June 2012 for initial febrile UTIs, 31% underwent VCUG. Between January and June 2011 – before the updated Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months was released – 72% of 172 children in that age group had a VCUG, Dr. Kirsch said during a press briefing at the meeting.
The earlier and later cohorts were similar. They did not differ with respect to admissions for febrile UTI; 27% and 24% of patients in the cohorts, respectively, required hospitalization. The percentage of positive VCUGs also was similar in the cohorts at 36% and 38%, respectively. The mean maximum vesicoureteral reflux grade was similar at 2.9 and 2.5, respectively.
The number of renal and bladder ultrasounds obtained decreased by 17% in 2012 as compared to 2011; ultrasounds were obtained in 58% of patients in the later cohort, compared with 76% of those in the earlier cohort.
There was no association between abnormal renal and bladder ultrasound and VCUG positivity (P = .116), he noted.
About 60% of children diagnosed with vesicoureteral reflux in both cohorts were found to have moderate to severe reflux. A trend toward detection of higher-grade vesicoureteral reflux prior to guideline publication also raises concern that higher grade reflux – which has been associated with an increased risk of recurrent febrile UTIs and renal scarring – is being missed, he said.
Whether foregoing routine VCUG following initial febrile UTI as recommended by the AAP guidelines will result in increased morbidity from undiagnosed vesicoureteral reflux, or whether the guidelines should apply to all patients in the emergency setting, requires careful reevaluation, he concluded.
Dr. Kirsch reported having no disclosures.