PEDIATRICS Vol. 123 No. 2 February 2009, pp. e239-e246 (doi:10.1542/peds.2008-1003)
ARTICLE |
Value of Imaging Studies After a First Febrile Urinary Tract Infection in Young Children: Data From Italian Renal Infection Study 1
a Departments of Pediatric Nephrology
b Nuclear Medicine
c Radiology
d Urology, Azienda Ospedaliera, University of Padua, Padua, Italy
e Pediatric Unit, Hospital of Bassano, Bassano del Grappa, Italy
f Pediatric Unit, Hospital of Dolo, Dolo, Italy
g Pediatric Unit, Hospital of Faenza/Lugo, Lugo, Italy
h Pediatric Unit, Hospital of Imola, Imola, Italy
i Pediatric Unit, Hospital of Monselice, Monselice, Italy
j Pediatric Unit, Hospital of Venice, Venice, Italy
k Pediatric Unit, Hospital of Forli, Forli, Italy
l Pediatric Unit, Hospital of San Donà di Piave, San Donà di Piave, Italy
m Pediatric Unit, Hospital of Feltre, Feltre, Italy
n Pediatric Unit, Hospital of Pordenone, Pordenone, Italy
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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OBJECTIVE. We examined the diagnostic accuracy of routine imaging studies (ultrasonography and micturating cystography) for predicting long-term parenchymal renal damage after a first febrile urinary tract infection.
METHODS. This study addressed the secondary objective of a prospective trial evaluating different antibiotic regimens for the treatment of acute pyelonephritis. Data for 300 children 
2 years of age, with normal prenatal ultrasound results, who completed the diagnostic follow-up evaluation (ultrasonography and technetium-99m-dimercaptosuccinic acid scanning within 10 days, cystography within 2 months, and repeat technetium-99m-dimercaptosuccinic acid scanning at 12 months to detect scarring) were analyzed. Outcome measures were sensitivity, specificity, and negative and positive predictive values for ultrasonography and cystography in predicting parenchymal renal damage on the 12-month technetium-99m-dimercaptosuccinic acid scans.
RESULTS. The kidneys and urinary tracts were mostly normal. The acute technetium-99m-dimercaptosuccinic acid scans showed pyelonephritis in 54% of cases. Renal scarring developed in 15% of cases. The ultrasonographic and cystographic findings were poor predictors of long-term damage, showing minor sonographic abnormalities for 12 and reflux for 23 of the 45 children who subsequently developed scarring.
CONCLUSIONS. The benefit of performing ultrasonography and scintigraphy in the acute phase or cystourethrography is minimal. Our findings support (1) technetium-99m-dimercaptosuccinic acid scintigraphy 6 months after infection to detect scarring that may be related to long-term hypertension, proteinuria, and renal function impairment (although the degree of scarring was generally minor and did not impair renal function) and (2) continued surveillance to identify recurrent urinary tract infections that may warrant further investigation.
Key Words: pyelonephritis • scintigraphy • ultrasonography • urinary tract infection • vesicoureteric reflux • renal scarring
Abbreviations: DMSA—technetium-99m-dimercaptosuccinic acid • UTI—urinary tract infection • APN—acute pyelonephritis • PPV—positive predictive value • NPV—negative predictive value • RRF—relative renal function • NICE—National Institute for Health and Clinical Excellence • CI—confidence interval
Febrile urinary tract infection (UTI) is now considered the most common serious bacterial infection occurring in infancy and early childhood in the developed world.1 A proportion of children (10%–30%) with febrile UTIs develop renal scarring, which is thought to be a risk factor for hypertension and renal insufficiency in the longer term.2
Various imaging investigations (including ultrasonography, voiding cystography, and technetium-99m-dimercaptosuccinic acid [DMSA] scintigraphy) after a first febrile UTI have been recommended widely, with the objective of identifying pathologic malformations and/or risk factors that, if not diagnosed and managed appropriately, might lead to additional infections and ongoing renal parenchymal damage.3 Evidence of the value of these imaging studies in changing management approaches or affecting subsequent outcomes is limited,3,4 especially today, given the questionable role of antibiotic prophylaxis.5–9
In the past, most studies10–14 concentrated on the prevalence of urologic abnormalities and not the effect that early detection and management of anomalies might have on preventing subsequent renal parenchymal damage. Hoberman et al12 suggested that renal ultrasonography and renal scanning at the time of the acute illness are of limited value, because they do not provide information that modifies management. Those authors recommended voiding cystourethrography, only under the assumption that antimicrobial prophylaxis is effective in reducing the incidence of reinfection and renal scarring. We consider scarring to be the most important end point, because long-term medical consequences (proteinuria, hypertension, and chronic kidney damage) are generally associated with its presence.15–17
There is a lack of consensus among published guidelines regarding the best investigative approach for evaluating young children presenting with their first febrile UTI (Table 1). Of interest, the National Institute for Health and Clinical Excellence (NICE)21 recently published extensive guidelines for the management of UTIs in children. The recommendations for investigation are complex, with multiple tables dividing children into different age groups and with UTIs classified into different variants, combinations of which determine the nature and timing of subsequent imaging studies. Acknowledging uncertainty in this area, the Guideline Development Group made research recommendations, encouraging well-designed prospective studies to evaluate both management and imaging investigations for UTIs.
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We undertook an evaluation of the diagnostic protocol used in a prospective study, Italian Renal Infection Study 1, that compared oral antibiotic treatment alone with initial parenteral treatment for young children presenting with their first febrile UTI.22 This evaluation was the secondary objective of the study and assessed the diagnostic accuracy of the various imaging techniques for their ability to predict parenchymal renal damage, warranting ongoing follow-up monitoring.
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METHODS |
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Study Protocol
The study took place between June 2000 and July 2005 at 28 pediatric units located in northeast Italy and was coordinated by the nephrology, dialysis, and transplantation unit of the pediatric department of the University of Padua. The protocol was approved by the ethics committee of each participating center. Written informed consent was obtained from the parents before inclusion in the study.
The main entry criteria of the study were reported previously.22 Briefly, the study included children 1 month to <7 years of age, presenting with their first documented febrile UTIs, who had normal renal function and normal prenatal ultrasound findings for the renal tract. In Italy, it is routine practice to perform prenatal ultrasound studies at 12, 20, and 32 weeks of gestation. A clinical diagnosis of acute pyelonephritis (APN) was based on criteria 1 and 2 plus 
2 of the remaining criteria, as follows: (1) urinalysis of an uncentrifuged specimen (2 concordant consecutive tests) yielding a white blood cell count of 25 cells per µL (1+ with a dipstick); (2) urine culture (with urine collected by using sterile bags that were changed every 20–30 minutes; 2 concordant consecutive tests were required) yielding growth of only 1 microorganism at 100 000 colony-forming units per mL; (3) fever of 38°C (in the first 6 months of life, fever was not an essential criterion); (4) inflammatory indices in the first 48 hours, including an erythrocyte sedimentation rate of 30 mm/hour and/or C-reactive protein level 3 times the upper limit of normal values for each participating center; and/or (5) neutrophil levels greater than normal values for age.23 Patients were enrolled sequentially as far as was practical. Because children 2 years of age are considered most at risk of having urologic abnormalities and the majority of studies evaluating imaging approaches are restricted to this group, we elected to limit the analysis of the protocol to children 1 month to 2 years of age who had completed the diagnostic evaluation (Fig 1).
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Imaging Studies
Ultrasonography and DMSA renal scanning were performed no later than 10 days after commencement of antibiotic therapy. After treatment was completed, recruited subjects continued to receive antibiotic prophylaxis until voiding cystography was performed (within 2 months). All children with positive scanning results for APN were scheduled for repetition of the study after 1 year, to detect any renal scarring at the site of the original APN. Those with negative acute DMSA scanning results were not at risk of developing subsequent scarring, on the basis of a previous large study,12 and were considered negative according to the protocol.
Static renal scintigraphy was performed 3 to 4 hours after injection of a weight-scaled dose of DMSA; views were obtained in the posterior and both posterior oblique projections for 300 000 counts. Focal or diffuse areas of decreased uptake in the first scan, without evidence of cortical loss, were considered indicative of APN. Renal scarring was defined as decreased uptake with distortion of the contours or cortical thinning with loss of parenchymal volume. Static renal scintigraphy with DMSA is considered the standard method for identification of renal parenchymal localization of infection.24 Two nuclear medicine physicians, who were blinded to the patients’ test results, interpreted the scans independently. Discrepancies were resolved through discussion between the assessors. The ultrasound results were considered positive even when the morphologic changes were minimal (for example, mild dilation of the renal pelvis, mild increase in renal volume, any discernable increase in the thickness of the pelvic mucosa, or debris present in the bladder). Voiding cystography was performed with traditional radiography and contrast material; 1 filling was conducted during the procedure. Qualified radiologists in each of the participating centers performed ultrasonography and cystography. The radiologists were blinded to clinical, laboratory, and other data regarding the patients.
Statistical Analyses
The relationships between variables in terms of bivariate associations were assessed with the use of McNemar's 2-sided test. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), likelihood 95% confidence intervals (CIs), and P values were calculated to evaluate concordance. All statistical calculations were performed with Stata 8.1 (Stata Corp, College Station, TX).
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RESULTS |
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Study Group
Of the 502 children who were evaluated for the main objective of the trial,22 300 were between 1 month and 2 years of age (median age: 7 months; 188 girls) and had completed the diagnostic protocol summarized in Table 2. All children had normal renal function, as assessed with the formula described by Schwartz et al.25 No adverse events resulting from performance of the diagnostic follow-up tests were reported.
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Ultrasonography
A total of 262 ultrasound studies (87%) yielded negative results and 38 (13%) showed abnormalities, which were generally minor (dilated pelvis, ureter, or pelvis and calyces, n = 12; renal swelling or local parenchymal changes, n = 10; increased bladder wall or pelvic mucosa thickness, n = 6; other, n = 10). Of these, there was only 1 case (pelviureteric junction obstruction) in which clinical management was influenced by the ultrasound results, with the child undergoing pyeloplasty. Although normal ultrasound results indicated 214 of the 234 children without vesicoureteric reflux, ultrasonography had limited ability to identify those with reflux, indicating only 18 of 66 (PPV: 47.4%; 95% CI: 31.0%–64.2%; P < .001). The ability of ultrasonography to predict renal parenchymal damage, the most significant outcome, also was limited, with positive results for 12 of the 45 children who subsequently developed scarring at the site of the original APN (PPV: 31.6%; 95% CI: 17.5%–48.7%) (for additional details, see Table 3).
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Micturating Cystourethrography
A total of 234 studies (78%) yielded normal results, and 66 (22%) demonstrated vesicoureteric reflux. The vast majority of patients had a maximal grade of reflux of I to III, with only 3 children exhibiting grade IV reflux and 1 child grade V reflux. Of particular interest, the cystographic results were positive for reflux for only 23 of the 45 children who subsequently developed scarring, and results were negative for 212 of the 255 children with normal follow-up scintigraphic results (PPV: 34.8%; 95% CI: 23.5%–47.6%) (for additional details, see Table 3). All 4 children with grade IV/V reflux had abnormal follow-up DMSA scanning results, with evidence of scarring. The presence of high-grade reflux influenced the clinical treatment of these 4 patients, because all were given antibiotic prophylaxis.
Acute DMSA Scanning
The results of 139 studies (46%) were normal, and 161 studies (54%) exhibited findings consistent with acute APN. The relative renal function (RRF) was normal (<10% reduction for a single kidney) for 590 kidneys (98.5%). Ten kidneys had RRF of <40%, 1 of which had RRF of <30%.
DMSA Scanning at 12 Months
DMSA scanning was performed at 12 months for 171 children, 161 of whom had positive acute DMSA scanning results, and demonstrated scarring in 45 cases, yielding a scarring rate of 28% after a first confirmed episode of APN. An additional 10 children with negative acute scanning results underwent follow-up studies for various clinical reasons; none of those children demonstrated scarring. The rate of scarring for the children with a first febrile UTI was 15% (45 of 300 children). For the 10 kidneys with RRF of <40% at the acute DMSA scan, RRF did not decrease further; function returned to normal for 2 kidneys and scarring developed in the remaining 8 kidneys, including that with RRF of <30%. Only 1 kidney had a significant reduction in RRF (from 49% to 38%) between the acute and follow-up DMSA scans.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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UTIs are frequently diagnosed in the first 2 years of life among children with fever. These infections alert physicians to the possibility of additional problems, particularly the presence of renal tract malformations, with varying degrees of parenchymal dysplasia or damage that might have been present prenatally.
A vast quantity of work in the literature highlights an association between febrile UTIs and kidney damage, with the possibility of chronic renal insufficiency and hypertension.2 These studies refer quite often to case material collected before the 1980s, before the widespread introduction of prenatal ultrasound screening.16,26 This screening has revealed a large number of children who have congenital nephrourologic damage, which previously was attributed to reflux nephropathy.
The earlier studies suggested the need for extensive morphologic investigations, including ultrasonography, cystography, and scintigraphy in different combinations, to diagnose various malformations that are particularly common in children up to 2 years of age. It is necessary to review the rationale for those studies with young children, with an emphasis on how they might lead to a modification of management through either medical or surgical intervention, to avoid the development of subsequent renal damage. This is in accord with a systematic review that examined further investigation of UTIs in children.4 The authors recommended that tests be conducted only if the results would lead to a change in management and the change would likely lead to an improved outcome.
Ultrasonography is considered useful for detecting anatomic abnormalities of the kidneys and urinary tract. Being noninvasive, it is widely used after a first febrile UTI and has replaced intravenous pyelography as the preferred initial imaging method. In our study, it is probable that significant abnormalities had already been detected through prenatal screening, because we demonstrated a small proportion (13%) of abnormal ultrasound results, generally with minor changes. We emphasize that ultrasound results led to an alteration in management in only 1 instance, a case of pelviureteric junction obstruction that required surgical intervention. Therefore, we suggest a specific diagnostic role for ultrasonography, namely, for children for whom it was not performed prenatally, those with a poor response to antibiotics, and those with complicated or recurrent infections. Other studies and the NICE guidelines are in accord with our view of the limited benefit of routine ultrasonography.12,21,27
In our study, cystograms yielded positive results for 22% of children (66 of 300 children), with only 4 children exhibiting grade IV or V reflux; all 4 children were given antibiotic prophylaxis and represented a very small proportion (1.3%; 95% CI: 0.2%–2.4%) of the total population studied. For those few patients, clinical management might benefit from the use of cystography, if antibiotic prophylaxis is effective in preventing recurrent infection in high-grade reflux. However, use of cystography for 300 children to detect 4 cases of severe reflux, which could be found after a second febrile UTI, is not warranted.
The results of cystograms were poorly predictive of subsequent scarring (PPV: 34.8%; NPV: 90.6%). The mode of execution of cystography in our protocol allowed for 1 fill cycle, which might explain the relatively low positive result rates, compared with some other studies. Some authors recommend multiple refill cycles to obtain greater sensitivity.28,29 We think this increases the attendant risk of radiation for a marginal increase in sensitivity, with the additional reflux detected generally being of low grade.
Micturating cystourethrography has been widely recommended in the past, primarily to detect various degrees of vesicoureteric reflux. The impetus for performing cystourethrography stems from 2 prospective studies30,31 conducted >20 years ago that suggested that reflux was a major risk factor for recurrent APN and consequent renal scarring. Both studies compared surgical correction of the reflux with long-term antimicrobial therapy and found similar outcomes. Neither study had a control arm without treatment. Antibiotic prophylaxis or surgical correction was recommended for patients found to have vesicoureteral reflux, with the assumption that treatment prevented recurrent APN. More recently, this practice has been questioned, given the lack of evidence5,6 and the publication of 3 separate trials7–9 that suggested that antibiotic prophylaxis does not reduce the overall incidence of UTIs in children with low-grade vesicoureteral reflux. The recent NICE guidelines21 do not support the administration of antibiotics and even question whether they may be harmful, inducing antibiotic resistance. Furthermore, a number of studies, including 1 systematic review and a meta-analysis,32,33 have questioned the value of investigating for vesicoureteric reflux as a predictor of renal damage.
It is important to clarify which "end point" should be used to evaluate the efficacy of the investigations undertaken. In much of the literature, considerable attention is placed on the diagnosis of reflux, with the conclusion that the only useful examination after a first febrile UTI is a micturating cystogram.12 However, damage in the longer term is associated with parenchymal scarring and, as we demonstrated, along with other reports in the literature,32,33 this is largely independent of the presence of reflux. Therefore, we maintain that most attention should be concentrated on the final outcome of renal scarring, as has been suggested,34 rather than the presence of reflux. If detection of vesicoureteral reflux is poorly correlated with subsequent renal scarring, with no evidence that the diagnosis improves outcomes or warrants alterations in management, then this invasive procedure has little role in the routine investigation of a first febrile UTI. We cannot endorse cystography as a routine investigation, on the basis of our results.
Acute-phase DMSA scanning is useful for demonstrating parenchymal localization of the infection. Results were consistent with APN in 54% of cases, which was lower than the incidence reported in the original study (63%).22 This is likely attributable to exclusion of 63 children with positive acute DMSA scan results who did not participate in the follow-up study and inclusion of all children with negative acute DMSA scan results, according to protocol. It is more important to emphasize that obtaining an acute DMSA scan does not alter therapeutic behavior because, as we demonstrated, administering antibiotics intravenously or orally has no influence on outcomes.22 Given these findings, we question the value of routinely performing acute scintigraphy.
The majority of children in this analysis, 85% (255 of 300 children), did not develop subsequent scarring. The scars identified were relatively small and in most cases were observed in kidneys with otherwise normal function; significant loss of renal function was seen in only 1 of the 342 kidneys for which scintigraphy was performed at the 1-year follow-up evaluation. The few children with damage on follow-up DMSA scans and those with recurrent febrile infections should be considered for further investigation. Blood pressure and proteinuria should be monitored for children with scars. The real impact of such scars on the state of health of children and the development of long-term complications has yet to be determined. If reflux is at all important, then it is likely to be so only in the severe grades; we emphasize that all 4 children with grade IV/V reflux in this study had scarring on DMSA scans and thus would have been detected as having renal parenchymal damage in the absence of a cystogram. On the basis of our data, follow-up DMSA scanning at 12 months is the best examination to identify the most significant end point of renal parenchymal damage. Performing the study 6 months after the febrile UTI may enhance compliance with follow-up evaluations.
Our study has some limitations. The most important refers to loss to follow-up monitoring of 63 children with positive initial DMSA scan results (Fig 1). This could introduce a selection bias, because children with positive acute DMSA scan results are those at risk of kidney damage. The method of urine collection could be seen as another limitation. In our study, urine samples were collected by using sterile bags, which have a higher possibility of contamination. This increased risk of contamination represents the rationale for collecting the urine twice; 2 consecutive concordant urinalyses and cultures were required for diagnosis. Furthermore, urine collection was performed with a standardized protocol, which required changing the bag every 20 to 30 minutes. The proportion of children with pyelonephritis detected with scintigraphy after a febrile UTI (63.5%) in our original study22 agreed favorably with the results (63.5% and 61%) of 2 similar studies35,36 in which urine was collected with a catheter or midstream. This finding supports similar low rates of contamination in our cases.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Our data demonstrate the lack of clinical usefulness of routinely performing ultrasonography, scintigraphy in the acute phase, and micturating cystography after a first febrile UTI for small children with normal prenatal ultrasound results. The yields of these tests are low, and positive test results lead to either no change in management or changes that have uncertain benefits for the patients.
The data presented support performing, as a diagnostic evaluation, (1) scintigraphy 6 to 12 months after the acute infection to detect renal parenchymal damage and (2) surveillance to identify recurrent UTIs that may warrant further investigation. In the absence of prenatal ultrasound evaluations, it would be reasonable to perform ultrasonography to exclude the possibility of congenital genitourinary malformations. This approach would allow detection of children who develop renal scarring and thus require continued follow-up monitoring; it would result in reduced radiation doses, compared with performing acute DMSA scanning with a repeat study for those with APN. It would also decrease the psychological stress to which we subject our small patients and would reduce the significant costs associated with ultrasonography, cystography, and scintigraphy in the acute phase.
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ACKNOWLEDGMENTS |
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This study was supported by grants from the Region of Veneto (research project 40/01) and the nonprofit association "Il Sogno di Stefano" ("Stephen's Dream"), which provides support to children with renal disease.
Participants in Italian Renal Infection Study 1 were: Dr I. Marella and Dr A. Budini (Pediatrics Department, Hospital of Adria); Dr L. Marcazzò and Dr S. Bellato (Pediatrics Department, Hospital of Arzignano); Dr G. Audino and Dr G. Picco (Pediatrics Department, Hospital of Bassano); Prof P. Colleselli and Dr D. Scorrano (Pediatrics Department, Hospital of Belluno); Prof L. Pavanello (Pediatrics Department, Hospital of Castelfranco); Dr C. Crivellaro (Pediatrics Department, Hospital of Chioggia); Dr G. Cattarozzi, Dr M. Pitter, and Dr A. Ballan (Pediatrics Department, Hospital of Dolo/Mirano); Dr F. Rossetti and Dr V. Cannella (Pediatrics Department, Hospital of Este/Monselice); Dr G. Svaluto-Moreolo and Dr V. Caddia (Pediatrics Department, Hospital of Feltre); Prof F. Donzelli and Dr F. Maschio (Pediatrics Department, Hospital of Mestre); Dr P. Brisotto, Dr N. Crema, and Dr S. Breseghella (Pediatrics Department, Hospital of Montebelluna); Dr P. Luxardo and Dr A. Toffolo (Pediatrics Department, Hospital of Oderzo); Prof G. Zacchello, Dr G. Montini, Dr L. Murer, Dr C. Carasi, Dr B. Andreetta, Dr S. Comacchio, Dr L. Rigon, Dr S. Sartori, Dr L. Tomasi, Dr R. Pertile, Dr I. Hewitt, Dr D. Gobber (epidemiologist), and Dr A. Ponzoni (statistician) (Pediatrics Department, Hospital of Padua); Dr A. Truini (Pediatrics Department, Hospital of Piove di Sacco); Dr P. G. Flora and Dr M. Ranieri (Pediatrics Department, Hospital of San Donà); Dr R. Dall'Amico and Dr L. Donello (Pediatrics Department, Hospital of Thiene); Dr G. Marcer and Dr S. Zanchetta (Pediatrics Department, Hospital of Soave); Prof M. Del Majno and Dr M. Gheno (Pediatrics Department, Hospital of Venice); Dr P. Biban and Dr P. Fortunati (Pediatrics Department, Hospital of Verona-Borgo Trento); Dr M. G. Santangelo and Dr O. Gianesini (Pediatrics Department, Hospital of Vicenza); Dr A. Corsini (Pediatrics Department, Hospital of Bentivoglio); Dr P. P. Molinari (Pediatrics Department, Bologna General Hospital); Dr A. Zucchini (Pediatrics Department, Hospital of Faenza/Lugo); Dr A. Venturolli (Pediatrics Department, Hospital of Forlì); Dr L. Serra (Pediatrics Department, Hospital of Imola); Dr L. Casadio (Pediatrics Department, Hospital of Ravenna); Dr M. Principi (Pediatrics Department, Hospital of Macerata); Dr P. Pitschiller and Dr W. Cassar (Pediatrics Department, Hospital of Bolzano); and Dr M. De Marini and Dr C. Crescenzi (Pediatrics Department, Hospital of Cuneo).
We thank all members of the Italian Renal Infection Study group, who made the performance of this study possible. We particularly thank Dr Daniela Gobber (epidemiologist), who unfortunately died 2 years ago. We thank Dr Andrea Ponzoni for statistical analysis.
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FOOTNOTES |
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Accepted Oct 17, 2008.
Address correspondence to Giovanni Montini, MD, Nephrology, Dialysis, and Transplant Unit, Pediatric Department, Azienda Ospedaliera, University of Padua, Via Giustiniani, 3, 35128 Padua, Italy. E-mail: montini{at}pediatria.unipd.it
The authors have indicated they have no financial relationships relevant to this article to disclose.
This trial has been registered at www.clinicaltrials.gov (identifier NCT00161330).
| What's Known on This Subject Ultrasonography, voiding cystography, and DMSA scintigraphy have been recommended after febrile UTIs, although evidence of their value is limited. Furthermore, recent trials suggest that antibiotic prophylaxis does not reduce the incidence of UTIs in children with low-grade vesicoureteral reflux.
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| What This Study Adds The benefit of ultrasonography and scintigraphy in the acute phase of febrile UTIs or cystourethrography is minimal. Scintigraphy 6 months after infection allows the detection of children who have developed renal parenchymal damage and will need medical follow-up care.
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