Published online November 1, 2006
PEDIATRICS Vol. 118 No. 5 November 2006, pp. 2251 (doi:10.1542/10.1542/peds.2006-1512)

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LETTER TO THE EDITOR

Much Pain, Little Gain From Voiding Cystourethrograms After Urinary Tract Infection

Thomas B. Newman, MD, MPH
Department of Epidemiology
University of California, San Francisco
San Francisco, CA 94143-0560

To the Editor.—

Garin et al¹ recently reported results of a multicenter randomized trial of antibiotic prophylaxis to prevent recurrent urinary tract infections and renal scarring in children 3 months to 18 years old with a history of pyelonephritis. Among patients with (grades I–III) vesicoureteral reflux (VUR), 7 (12.9%) of 55 of those treated with prophylactic antibiotics developed recurrent pyelonephritis (all with resistant organisms), compared with 1 (1.7%) of 58 of those not treated (P = .029). Renal scars were also more common with antibiotics, occurring in 5 (9.0%) of 55 patients compared with 2 (3.4%) of the 58 controls.

In an accompanying commentary, Wald acknowledged that the study "provided compelling data indicating that urinary tract prophylaxis with currently available agents in children with low grades of VUR (I, II, and III) does not seem to be beneficial."² However, she cautioned that the conclusions may not apply to children with higher grades of reflux and stated, "Until such time that there are data to address the usefulness of prophylaxis in these latter cases, we must continue to recommend the performance of the VCUG [voiding cystourethrogram] to determine the presence of VUR and search for strategies to keep the urine free of infection in children with high degrees of VUR."

This last recommendation seems hard to justify. In a prospective study coauthored by Wald,³ only 4 (1.3%) of 306 children with febrile urinary tract infections had grade IV reflux, and none had grade V. Thus, 76 VCUGs would need to be done to identify each child with a grade IV reflux. This seems like a great deal of radiation, cost, and discomfort to identify a few children with an entity that we still do not know how to treat.

Invasive procedures such as the VCUG should be performed only when there is evidence of benefit. Such evidence has never existed for screening for VUR after urinary tract infections.^4–6 We now have evidence that the recommended treatment not only does not work but also may be harmful. As Winberg⁷ wrote about VUR in 1994, "It is psychologically difficult to accept results that suggest that time-honored methods that are generally recommended and applied are of no or doubtful value."

It has been 12 years; let's get over it! It is well past time to abandon routine VCUGs after urinary tract infections in infants and children.

FOOTNOTES

Statements appearing here are those of the writers and do not represent the offcial position of the American Academy of Pediatrics or its Committees. Comments on any topic, including the contents of PEDIATRICS, are invited from all members of the profession; those accepted for publication will not be subject to major editorial revision but generally must be no more than 400 words in length. The editors reserve the right to publish replies and may solicit responses from authors and others.

Please see www.pediatrics.org for instructions on submitting letters.

REFERENCES

1. Garin EH, Olavarria F, Garcia Nieto V, Valenciano B, Campos A, Young L. Clinical significance of primary vesicoureteral reflux and urinary antibiotic prophylaxis after acute pyelonephritis: a multicenter, randomized, controlled study. Pediatrics. 2006;117 :626 –632[Abstract/Free Full Text]
2. Wald ER. Vesicoureteral reflux: the role of antibiotic prophylaxis. Pediatrics. 2006;117 :919 –922[Free Full Text]
3. Hoberman A, Wald ER, Hickey RW, et al. Oral versus initial intravenous therapy for urinary tract infections in young febrile children. Pediatrics. 1999;104 :79 –86[Abstract/Free Full Text]
4. Dick P, Feldman W. Routine diagnostic imaging for childhood urinary tract infections: a systematic overview. J Pediatr. 1996;128 :15 –22[CrossRef][Web of Science][Medline]
5. Craig JC, Irwig LM, Knight JF, Roy LP. Does treatment of vesicoureteric reflux in childhood prevent end-stage renal disease attributable to reflux nephropathy? Pediatrics. 2000;105 :1236 –1241[Abstract/Free Full Text]
6. 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]
7. Winberg J. Management of primary vesico-ureteric reflux in children: operation ineffective in preventing progressive renal damage. Infection. 1994;22(suppl 1) :S4 –S7[CrossRef]

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PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics

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This article has been cited by other articles:

				E. H. Garin and L. Young Much Pain, Little Gain From Voiding Cystourethrogram After Urinary Tract Infection Pediatrics, July 1, 2007; 120(1): 249 - 250. [Full Text] [PDF]

This Article Extract Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services E-mail this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Newman, T. B. Search for Related Content PubMed PubMed Citation Articles by Newman, T. B. Related Collections Genitourinary Tract Social Bookmarking                         What's this?