Vesicoureteral reflux can put a child at risk of recurrent urinary tract infections (UTIs) and renal scarring. UTIs occurring in children younger than two years should be investigated with renal ultrasonography and either radionuclide or voiding cystourethrography. If a child has unknown or identified reflux, he or she should receive antimicrobial prophylaxis. Although these recommendations have not gone unchallenged, they remain usual care, particularly in high-risk children with uncertain follow-up. Cohen and colleagues sought to determine the extent to which these guidelines are followed.
This retrospective cohort study included children enrolled in a Medicaid program who were diagnosed with a UTI in the first year of life. Associated studies and antimicrobial prophylaxis carried out within three months of the diagnosis were evaluated. Of 780 patients identified as having a UTI in the first year of life, 302 were hospitalized. Almost 60 percent of patients were female, and most were white or Hispanic. Less than one half of all diagnosed children received anatomic imaging or imaging for reflux within the designated time frame. Less than one third (28.2 percent) received both types of imaging. One half (51 percent) of children who received imaging for reflux were given prophylactic antibiotics as recommended. The children who were hospitalized for UTI were significantly more likely to receive appropriate imaging (relative risk [RR], 1.38 for anatomic imaging and 1.62 for reflux imaging). Children 90 days or younger were less likely to receive antibiotic prophylaxis (RR, 0.59) than those older than 90 days. Managed care enrollment had no association with the work-up or prophylaxis.
This study, the authors conclude, shows a common finding—inadequate compliance with recommended guidelines. Less than one half of the children studied received recommended care. Hospitalized children were more likely to receive recommended care, possibly because coordination of care was easier, children were more acutely ill, testing could be completed during hospitalization, or clinical pathways mandated care. Further evidence-based studies on UTI work-up and better implementation of guidelines are warranted.
editor's note: In 1999, the American Academy of Pediatrics issued a practice parameter1 on evaluation of first-time urinary tract infection (UTI) in children age two months to two years, and these guidelines still stand. Since then, the literature has been expanded with similar recommendations for neonates, and continues to support the concomitant use of voiding cystourethrography for the detection of reflux and renal ultrasonography.2,3 A few dissenting voices have argued that studies of imaging after first UTI have not altered management or demonstrated patient-oriented outcomes such as a reduction in recurrent UTI and renal scarring.4—c.w.