PEDIATRICS Vol. 107 No. 4 April 2001, pp. 806

More on Urinary Tract Infection Guidelines

To the Editor.

In his question about urinary tract infection (UTI) guidelines, Dr Seidman¹ states that "many of us in practice have yet to have a renal ultrasound (RUS) result alter management. In this era of frequent prenatal ultrasounds is the yield of RUS worth the cost and inconvenience?" Dr Roberts et al, on behalf of the AAP Subcommittee on Urinary Tract Infection,² answer that no information is available regarding this matter. Unfortunately, it seems that the Subcommittee may have missed 2 publications that directly^3,4 and 1 that indirectly⁵ dealt with the matter. All 3 found that routine RUS in children with uncomplicated first UTI has negligible effect on clinical management. Furthermore, both Mucci and Maguire³ and we⁴ found that, indeed, the vast majority of major anatomic abnormalities in the urinary tract are being detected already by prenatal ultrasound. It was our conclusion that in industrialized countries in which maternal-fetal ultrasound is universally done, the practice of conducting routine RUS on every young child with first febrile UTI has to be reexamined. In essence, it seems that the prenatal ultrasound has replaced UTI-indicated ultrasound.

Naturally ultrasound should continue to be used in the child with a complicated course of pyelonephrosis, recurrent UTIs, presence of other congenital abnormalities, significant pathology detected in the lower urinary tract by imaging studies, and when it is suspected that the child did not have a late prenatal ultrasound.

Uri S. Alon
Children's Mercy Hospital
University of Missouri at Kansas City
Kansas City, MO 64108

REFERENCES

1. Seidman D Urinary tract infections guidelines questioned. Pediatrics. 2000; 105:464
2. Roberts KB, Hellerstein S, Downs SD. Urinary tract infections guidelines questioned. Pediatrics. 2000;105:466-467. Reply
3. Mucci B, Maguire B Does routine ultrasound have a role in the investigation of children with urinary tract infection? Clin Radiol. 1994; 49:324-325 [CrossRef][Medline]
4. Alon US, Ganapathy S Should renal ultrasonography be done routinely in children with first urinary tract infection? Clin Pediatr. 1999; 38:21-25 [Abstract/Free Full Text]
5. Hoberman A, Wald E Urinary tract infections in young febrile children. Pediatr Infect Dis J. 1997; 16:11-17 [CrossRef][Medline]

In Reply.

We appreciate Dr Alon's comments concerning the role of urinary tract ultrasonography in evaluation of UTI in an infant from 2 months to 2 years of age. The publications cited support the impression held by many that urinary tract ultrasonography rarely leads to alteration in management of the young infant with a UTI. Since the AAP practice parameter effort is to create products that are evidence-based, we point out the need for a good prospective study to document the value or lack of value of ultrasonography when an infant who had a normal late-pregnancy intrauterine ultrasound develops a UTI. Despite the absence of such data, we acknowledge that many clinicians are comfortable not performing urinary tract ultrasonography after a UTI if the following conditions are met: The infant has had a normal, late-pregnancy ultrasound and clearly has a normal voiding pattern, no abdominal mass, a good response to treatment of the UTI, and a normal basic metabolic panel when rehydrated.

Stanley Hellerstein
Kenneth B. Roberts
For the AAP Subcommittee on Urinary Tract Infection