Response to the AAP Section on Urology Concerns About the AAP Urinary Tract Infection Guideline

The American Academy of Pediatrics (AAP) Section on Urology (SOU)¹ raises several concerns regarding the new AAP Urinary Tract Infection (UTI) Clinical Practice Guideline.² The SOU takes issue with the 6 randomized controlled trials that assess the effectiveness of prophylaxis.^3–8 Specifically, the SOU draws attention to the use of bag specimens; the lack of information about circumcision, elimination habits, and compliance; and the small number of subjects in the individual studies.

• The SOU states that the studies “depend heavily on data from bag specimens.” We acknowledge that bag specimens were not precluded in 3 of the studies—including the Swedish Reflux Trial that the SOU cites in support of prophylaxis.⁸ When used, false-positive cultures would be expected to occur in intervention and control groups, resulting in a bias toward the null, and the observed rates of UTI recurrence would be inflated. The relative effectiveness of prophylaxis would appear to be reduced, but, of greater importance, any absolute difference in effectiveness would remain.

• Uncircumcised status may increase the risk of recurrent UTI, or false-positive cultures, in boys in both intervention and control groups; however, boys were a minority of the subjects in the randomized controlled trials, so uncircumcised status is unlikely to mask a large benefit among the girls.

• We agree that bowel and bladder habits can have a marked influence on the incidence of UTI in children at and beyond the age of toilet training but emphasize that the AAP Guideline applies only to infants 2 to 24 months of age. It is not clear how much of a factor elimination habits are in this age group, and …

Address correspondence to Kenneth B. Roberts, MD, 3005 Bramblewood Dr, Mebane, NC 27302. E-mail: kenrobertsmd{at}gmail.com