Published online September 30, 2005
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, MD
Pediatric 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) guideline–recommended 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 infection–induced 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.3–11
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.1,2,13–15 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.1,2,14–16 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.
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