PEDIATRICS Vol. 116 No. 4 October 2005, pp. 1051-1052 (doi:10.1542/peds.2005-1471)
Compliance With Guidelines for the Medical Care of First Urinary Tract Infections in Infants
Roberto Jodorkovsky, MDPediatric Nephrology,
Brooklyn Hospital Center,
Brooklyn, NY 11201
To the Editor.
Cohen et al1 found poor compliance with the most recent American Academy of Pediatrics (AAP) guidelinerecommended care for the first urinary tract infection (UTI) in infants in a Medicaid population.2 This was particularly significant in outpatients. The authors suggested that, given the trend toward increased outpatient management of UTIs, increased attention should be given to the guidelines. Perhaps this study should cause no disappointment but rather encouragement to stimulate a comprehensive reanalysis of the AAP guidelines.
The ultimate goal of the AAP recommendations is to prevent the development of kidney infectioninduced renal scarring leading to hypertension and renal insufficiency.2 It is well accepted that acute bacterial infections can scar kidneys. Fortunately, not every child experiencing a kidney infection develops kidney damage. The pathogenesis of infection-induced scarring is complex and not fully elucidated yet. Renal scar formation is likely to require the presence of underlying predisposing risk factors in many children. These factors are multiple, and the influence of each of them is variable on an individual basis. Risk factors frequently involved are young age, delayed treatment of the infection, number of acute pyelonephritis events, certain bacterial strains (such as P-fimbriated), degree of adherence of bacteria to urogenital receptors, presence of obstructive uropathy (including neurogenic bladder), vesicoureteral reflux (VUR) (mostly grades 3 and above), and bladder dysfunction, particularly when it is associated with the angiotensin-converting enzyme insertion/deletion (ACE I/D) gene polymorphism.311
The guidelines recommend performing a renal ultrasound and a voiding cystourethrogram after a first urinary tract infection in young children.2 Although kidney ultrasonography is an acceptable screening method to detect obstructive uropathies, its low incidence has led some authors to question the cost-effectiveness and practicality of this test.12
The most common anatomic anomaly diagnosed is VUR, and a voiding cystourethrogram is the most sensitive technique to diagnose it. However, the inconvenience, cost, radiation exposure, and psychological distress associated with this procedure would justify its routine use only if the treatment of VUR proved to be effective in reducing the incidence of renal scarring.12 This issue is far from being clear. Antireflux surgery has shown no superiority over medical treatment in preventing renal damage.13 Medical treatment usually refers to prophylactic antibiotics, often lasting several years.1,2,1315 The AAP guidelines and several authors, including Cohen et al, recognize that there is a dearth of well-designed, placebo-controlled studies demonstrating the effectiveness of this treatment approach on renal damage.1,2,1416 On the other hand, the negative effects of chronic antibiotic use, such as the emergence of bacterial resistance and bacterial overgrowth around the urethral orifice, are well established.15,17
Practitioners showing poor adherence to the AAP recommendations may be reacting, knowingly or unknowingly, to the unpersuasive aspects of the guidelines. The unavoidable reality is that it is still unsubstantiated whether conducting routine imaging studies after the first UTI in infants and treating children showing VUG with prophylactic antibiotics bear any significant impact on the prevention of kidney damage and its complications. Poor compliance to the AAP recommendations should not be lamented until a revised version of the AAP guidelines based on new and solid evidence-based research addressing the controversial issues highlighted above and the critical role of multiple risk factors involved in the genesis of infection-induced renal scarring materializes.
REFERENCES
- Cohen AL, Rivara FP, Davis R, Christakis DA. Compliance with guidelines for the medical care of first urinary tract infections in infants: a population-based study.
Pediatrics. 2005;115
:1474
1478
[Abstract/Free Full Text] - American Academy of Pediatrics, Committee on Quality Improvement, Subcommittee on Urinary Tract Infection. Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children.
Pediatrics. 1999;103
:843
852
[Abstract/Free Full Text] - Kostic M, Stankovic A, Zivkovic M, et al. ACE and AT1 receptor gene polymorphism and renal scarring in urinary bladder dysfunction. Pediatr Nephrol. 2004;19 :853 857[Medline]
- Martinell J, Hansson S, Claesson I, Jacobson B, Lidin-Janson G, Jodal U. Detection of urographic scars in girls with pyelonephritis followed for 1338 years. Pediatr Nephrol. 2000;14 :1006 1010[Medline]
- Nuutinen M, Uhari M. Recurrence and follow-up after urinary tract infection under the age of 1 year. Pediatr Nephrol. 2001;16 :69 72[Medline]
- Levtchenko E, Lahy C, Levy J, Ham H, Piepsz A. Treatment of children with acute pyelonephritis: a prospective randomized study. Pediatr Nephrol. 2001;16 :878 884[CrossRef][Medline]
- Lin KY, Chiu NT, Chen MJ, et al. Acute pyelonephritis and sequelae of renal scar in pediatric first febrile urinary tract infection. Pediatr Nephrol. 2003;18 :362 365[Medline]
- Kaack MB, Pere A, Korhonen TK, Svenson SB, Roberts JA. P-fimbriae vaccines. I. Cross reactive antibodies to heterologous P-fimbriae. Pediatr Nephrol. 1989;3 :386 390
- Smellie JM, Ransley PG, Normand ICS, Prescod N, Edwards D. Development of new renal scars: a collaborative study. Br Med J (Clin Res Ed). 1985;290 :1957 1960
- Roberts J. Factors predisposing to urinary tract infections in children. Pediatr Nephrol. 1996;10 :517 522[CrossRef][Web of Science][Medline]
- Hiraoka M, Hashimoto G, Tsuchida S, Tsukahara H, Ohshima Y, Mayumi M. Early treatment of urinary infection prevents renal damage on cortical scintigraphy. Pediatr Nephrol. 2003;18 :115 118[Medline]
- Hoberman A, Charron M, Kickey R, Baskin M, Kearney D, Wald E. Imaging studies after a first febrile urinary tract infection in young children.
N Engl J Med. 2003;348
:195
202
[Abstract/Free Full Text] - Weiss R, Duckett J, Spitzer A. Results of a randomized clinical trial of medical versus surgical management of infants and children with grades III and IV primary vesicoureteral reflux (United States). The International Reflux Study in Children. J Urol. 1992;148 :1667 1673[Web of Science][Medline]
- Hellerstein S, Nickell E. Prophylactic antibiotics in children at risk for urinary tract infection. Pediatr Nephrol. 2002;17 :506 510[CrossRef][Web of Science][Medline]
- Williams G, Lee A, Craig J. Antibiotics for the prevention of urinary tract infection in children: a systematic review of randomized controlled trials. J Pediatr. 2001;138 :868 874[CrossRef][Web of Science][Medline]
- Wheeler D, Vimalachandra D, Hodson EM, Roy LP, Smith G, Craig JC. Antibiotics and surgery for vesicoureteric reflux: a meta-analysis of randomised controlled trials.
Arch Dis Child. 2003;88
:688
694
[Abstract/Free Full Text] - Winberg J, Herthelius-Elman M, Mollby R, Nord CE. Pathogenesis of urinary tract infectionexperimental studies of vaginal resistance to colonization. Pediatr Nephrol. 1993;7 :509 514[Medline]
PEDIATRICS (ISSN 1098-4275). ©2005 by the American Academy of Pediatrics
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