Published online July 1, 2008
PEDIATRICS Vol. 122 No. 1 July 2008, pp. 216 (doi:10.1542/peds.2008-1199)

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LETTER TO THE EDITOR

Therapeutic Delay in Infant Urinary Tract Infection: Does It Really Have No Impact?: In Reply

Dimitrios Doganis, MD
First Department of Pediatrics

Konstantinos Sinaniotis, MD
Second Department of Pediatrics
"P&A Kyriakou" Children's Hospital
11523 Athens, Greece

We read with great interest the comments of Geier et al on the role of the early treatment of infants with urinary tract infection (UTI).¹ The authors point out that our conclusion may lead to a misunderstanding that early treatment of acute febrile UTIs has no affect on outcome. On the contrary, in our study, renal involvement during infection was positively correlated with the day that infants received their first dose of antibiotic. Nevertheless, we did not detect a significant effect of the early treatment on scar formation, but as we have already pointed out, this could have been the result of the small number of patients studied. Our findings are in agreement with the findings of others who have found no difference in therapy delay between those with or without scars,² which suggests that renal scars are caused by the infection itself and that if the kidney is involved the risk for development of scarring is independent of the timing of therapy.

Several studies have shown that scarring only occurred at sites that corresponded to scintigraphic changes on the initial dimercaptosuccinic acid (DMSA) scan, confirming the primary role of the acute infection in the etiology of scarring and the reliability of the initial scan findings for identifying those infants at risk.^3,4 Consequently, it becomes obvious that when avoiding initial renal involvement, the permanent kidney damage is prevented.

Concerning the comment that only infants with an initial abnormal scintigraphy result underwent a follow-up investigation, we believe that it was not ethical to expose children without scan changes during the infection to the radiation of a second DMSA scan.

Geier et al comment also on the potential effect of age on our results. Renal involvement in the acute phase of infection was more common with advancing age, but the effect of early treatment in the development of renal changes was found to be independent of the age of the patients. Moreover, the difference between younger and older infants concerning scarring did not reach a significant level, which is in agreement with previous studies.⁵

Finally, regarding the role of vesicoureteral reflux (VUR), we detected that the presence of VUR did not differ according to time of therapy and did not influence the effect of therapeutic delay on DMSA results. Moreover, it is well known that VUR is a poor predictor of scarring, confirming that renal parenchymal infection rather than VUR is the prerequisite for acquired renal scarring.⁶

REFERENCES

1. Doganis D, Siafas K, Mavrikou M, et al. Does early treatment of urinary tract infection prevent renal damage? Pediatrics.2007; 120 (4). Available at: www.pediatrics.org/cgi/content/full/120/4/e922
2. Hoberman A, Wald ER, Hickey RW, et al. Oral versus initial intravenous therapy for urinary tract infections in young febrile children. Pediatrics.1999; 104 (1 pt 1):79 –86[Abstract/Free Full Text]
3. Rushton HG, Majd M. Dimercaptosuccinic acid renal scintigraphy for the evaluation of pyelonephritis and scarring: a review of experimental and clinical studies. J Urol.1992; 148 (5 pt 2):1726 –1732[Web of Science][Medline]
4. Roberts JA. Etiology and pathophysiology of pyelonephritis. Am J Kidney Dis.1991; 17 (1):1 –9[Web of Science][Medline]
5. Goldman M, Bistritzer T, Horne T, Zoareft I, Aladjem M. The etiology of renal scars in infants with pyelonephritis and vesicoureteral reflux. Pediatr Nephrol.2000; 14 (5):385 –388[CrossRef][Web of Science][Medline]
6. Rushton HG, Majd M, Jantausch B, Wiedermann BL, Belman AB. Renal scarring following reflux and nonreflux pyelonephritis: evaluation with 99m technetium-dimercaptosuccinic acid scintigraphy. J Urol.1992; 147 (5):1327 –1332[Web of Science][Medline]

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PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics

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This Article Extract Full Text (PDF) Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in Web of Science Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Doganis, D. Articles by Sinaniotis, K. Search for Related Content PubMed Articles by Doganis, D. Articles by Sinaniotis, K. Related Collections Genitourinary Tract Social Bookmarking                         What's this?