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Infantile urinary tract infection and timing of micturating cystourethrogram
Journal of Pediatric Urology (2010) 6, 582e584
Infantile urinary tract infection and timing of micturating cystourethrogram Giampiero Soccorso a, Gail Moss b, Julian Roberts a, Prasad Godbole a,* a b
Department of Paediatric Urology, Sheffield Children’s NHS Foundation Trust, Western Bank, Sheffield S10 2TH, UK Department of Paediatrics, Sheffield Children’s NHS Foundation Trust, Western Bank, Sheffield S10 2TH, UK
Received 19 October 2009; accepted 10 January 2010 Available online 25 February 2010
KEYWORDS UTI; Infant; MCUG
Abstract Objective: The investigation of infantile febrile urinary tract infection (UTI) is still a subject of debate and controversy. To evaluate for vesicoureteric reflux (VUR) most authorities recommend a micturating cystourethrogram (MCUG) to be performed at least 4 weeks after UTI to avoid false positive. Patients and methods: At a tertiary centre for paediatric specialities, information on 427 infants who had undergone MCUG following a first febrile UTI was prospectively recorded and their case notes reviewed. The infants were divided into two groups: Group A (117) with MCUG performed less than 4 weeks from UTI diagnosis and Group B (310) with MCUG after at least 8 weeks from diagnosis. Results: Of the 427 children, VUR was detected in 33% of those for whom MCUG was performed less than 4 weeks after UTI diagnosis and in 24% of those for whom it was performed at least 8 weeks after diagnosis. Conclusion: Neither the prevalence nor the grade of VUR in infants with a first episode of UTI is influenced by the timing of the MCUG following diagnosis. We therefore suggest that it is better to perform an MCUG as soon as possible, provided inflammation has subsided. ª 2010 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Introduction UTI is a common problem in children, and VUR, predisposing factor for recurrent pyelonephritis, is the most common anomaly of the urinary tract of infants and young children [1]. Current practice guidelines recommend MCUG to evaluate
* Corresponding author. Tel.: þ44 114 2717000; fax: þ44 114 271 7649. E-mail address: [email protected] (P. Godbole).
reflux [2,3]. The traditional interval between UTI and MCUG is 4e6 weeks to avoid false positives arising from transient reflux following inflammation and/or overestimation of ureteral dilatation during the acute infective phase [4,5]. However, the literature does not provide strong evidence to support this practice. Furthermore, recent studies in young children and infants with first UTI did not find a relationship between the presence or severity of VUR and the timing of the MCUG when this was performed later than 1 week [6,7]. More recently, the study of Doganis et al., focused on an infantile population, showed that an early MCUG (within 1 week of UTI
1477-5131/$36 ª 2010 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2010.01.008
Infantile UTI and timing of MCUG
583
diagnosis and establishment of treatment) does not result in increased false positive cystograms [8]. We have reviewed our experience of infants with a first febrile UTI looking at the timing of MCUG, aiming to find further evidence to justify an early cystogram following infantile UTI.
Methods We reviewed the records of all infants under 1 year of age presenting to a tertiary paediatric hospital between 1996 and 2006 with a first episode of febrile pyelonephritic illness. A febrile UTI was defined as pyrexia > 38 C associated with culture-proven pure growth of an organism >105 colony forming units/high-power field from an appropriately collected urine sample (clean-catch midstream urine sample or, where this was not possible, a suprapubic aspirate with ultrasound control). Our current practice is for all infants presenting with a febrile UTI to be admitted for intravenous antibiotics with subsequent chemoprophylaxis until investigations are complete. These infants undergo an ultrasound scan during admission followed by MCUG and DMSA scan as outpatients. The decision about the time scale of the MCUG was at the discretion of the attending paediatrician and paediatric radiologist; however, the traditional interval of at least 4e6 weeks after UTI was applied to the majority of the infants. We divided the patients into two groups according to the timing of the MCUG: less than 4 weeks of diagnosis of UTI (Group A) or after 8 weeks (Group B). The presence and severity of VUR were analysed in each group. None of the infants had their MCUG at exactly 4 weeks (28 days) after their UTI. Reflux was graded according to the international VUR classification [9]. Institutional ethics and clinical effectiveness committee approval was obtained for this study.
Results A total of 427 infants were eligible for enrolment. There were 258 boys (60%) and 169 girls (40%) with a median age of 5.2 months (0e12). All patients were started on prophylactic antibiotics until an MCUG was performed on an outpatient basis. One hundred and seventeen patients (Group A) had their MCUG performed less than 4 weeks after diagnosis of UTI and 310 patients (Group B) had an MCUG performed 8 weeks after infection diagnosis. Overall, 114 (27%) infants were found to have VUR as determined by MCUG. VUR was detected in 39 patients (33%) of Group A and in 75 infants (24%) of Group B (Table 1). This Table 1
Reflux and timing of MCUG. Group A
VUR No VUR Total
Group B
(MCUG < 4 weeks)
(MCUG > 8 weeks)
39 (33%) 78 (67%) 117
75 (24%) 235 (76%) 310
Chi-square Z 3.63, degrees of freedom Z 1, probability Z 0.057.
Table 2
Time between UTI diagnosis and VCUG.
No. of patients Gender Girls Boys Age Range (months) Median Prevalence of VUR Per patient (n Z 427) VUR grade I VUR grade II VUR grade III VUR grade IV VUR grade V
Group A
Group B
(MCUG < 4 weeks)
(MCUG > 8 weeks)
117 (27%)
310 (73%)
47 (40%) 70 (60%)
122 (39%) 188 (61%)
0.5e12 5.3
0.4e12 4.8
39 (33%) 5 (13%) 10 (26%) 20 (51%) 3 (8%) 1 (2%)
75 (24%) 6 (8%) 16 (21%) 39 (52%) 14 (19%) 0 (0%)
difference was not statistically significant (Chi-square Z 3.63, degrees of freedom Z 1, probability Z 0.057). Table 2 shows the characteristics of the patients and the distribution and grade of VUR in the two groups. There was no difference in severity of the VUR between the two groups (Table 2).
Discussion Our study offers further evidence that an early MCUG (within 4 weeks) following a first infantile UTI does not lead to an overestimation of the presence or grade of reflux. This study was retrospective and therefore there was no randomization of infants into early and late MCUG groups. The decision about the timing of the MCUG was at the discretion of the paediatrician or urologist. Moreover, the final timing of MCUG was dependent on the radiology department’s workload and on the attendance and availability of the patients’ parents: several missed appointments or cancellations and rescheduling were in fact the reasons why the median time for an MCUG in Group B was 9.6 weeks. Nevertheless, the sex and age distributions of infants were similar in the two groups, and the differences between the two groups concerning presence of VUR and severity were not statistically significant. The traditional practice of performing MCUG at a minimum of 4e6 weeks after UTI is based on the belief that an acute inflammatory process leads to transient reflux at the vesicoureteral junction; ureteral dilatation secondary to the effect of endotoxins released during UTI is also thought to result in over-estimation of the grade of reflux [10]. However, transient reflux and hydro-ureteronephrosis secondary to infection were found in animal studies done in the 1960s and to our knowledge have never been proved on human models [11]. Performing an MCUG sooner rather than later is safe, clinically useful and cost effective. MCUG performed soon after UTI resolution offers in fact the advantages of early diagnosis and instigation of a prompt management plan, stopping antibiotics earlier if not required, and earlier
584
G. Soccorso et al.
alleviation of parental anxiety which increases compliance. An MCUG should be performed once the infection has subsided and before the infant is discharged home; the ideal time will be within 1 week of UTI diagnosis. Randomized prospective studies are necessary to assess whether infants with their first UTI who are investigated with MCUG during the same admission (within 7 days from diagnosis) have the same outcome of those investigated at a later stage.
[3]
[4]
[5]
Conflict of interest None.
[6]
Funding source
[7]
None. [8]
Ethical approval Approved by committee.
the
clinical
effectiveness
and
audit
[9]
References [10] [1] Andrich M, Massoud M. Diagnostic imaging in the evaluation of first time urinary tract infection in infants and young children. Pediatrics 1992;90:436e41. [2] Report of a Working Group of the Research Unit Royal College of Physicians. Guidelines for the management of acute urinary
[11]
tract infection in childhood. J R Coll Physicians Lond 1991;25: 36e42. American Academy of Pediatrics Committe on Quality Improvement Subcommitte on Urinary Tract Infection. Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children. Paediatrics 1999;103:843e52. Hellerstein S. Classification of patients with urinary tract infections. In: Urinary tract infections in children. Chicago, IL: Yearbook Medical Publishers, Inc; 1982. p. 15e29. Rushton G, Belman B. Vesicoureteral reflux and renal scarring. In: Holliday M, Barratt M, Avner E, editors. Pediatric nephrology. 3rd ed. Baltimore, MD: Williams & Wilkins; 1994. p. 963e86. Mahant S, To T, Friedman J. Timing of voiding cystourethrogram in the investigation of urinary tract infections in children. J Pediatr 2001;139:568e71. Sathapornwajana P, Dissaneewate P, McNeil E, Vachvanichsanong P. Timing of voiding cystourethrogram after urinary tract infection. Arch Dis Child 2008;93:229e31. Doganis D, Mavrikou M, Delis D, Stamoyannou L, Siafas K, Sinaniotis K. Timing of voiding cystourethrography in infants with first time urinary infection. Pediatr Nephrol 2009;24: 319e22. Lebowitz RL, Olbing H, Parkkulainen KV, Smellie JM, TamminenMo ¨bius TE. International system of radiographic grading of vesicoureteric reflux. International Reflux Study in Children. Pediatr Radiol 1985;15:105e9. Hellstru ˚rild S, Wettergren B. Ureteral dila¨m M, Jodal U, Ma tation in children with febrile urinary tract infection or bacteriuria. AJR Am J Roentgenol 1987;148:483e6. Craig JC, Knight JF, Sureshkumar P, Lam A, Onikul E, Roy LP. Vesicoureteric reflux and timing of micturating cystourethrography after urinary tract infection. Arch Dis Child 1997;76:275e7.
Infantile urinary tract infection and timing of micturating cystourethrogram Giampiero Soccorso a, Gail Moss b, Julian Roberts a, Prasad Godbole a,* a b
Department of Paediatric Urology, Sheffield Children’s NHS Foundation Trust, Western Bank, Sheffield S10 2TH, UK Department of Paediatrics, Sheffield Children’s NHS Foundation Trust, Western Bank, Sheffield S10 2TH, UK
Received 19 October 2009; accepted 10 January 2010 Available online 25 February 2010
KEYWORDS UTI; Infant; MCUG
Abstract Objective: The investigation of infantile febrile urinary tract infection (UTI) is still a subject of debate and controversy. To evaluate for vesicoureteric reflux (VUR) most authorities recommend a micturating cystourethrogram (MCUG) to be performed at least 4 weeks after UTI to avoid false positive. Patients and methods: At a tertiary centre for paediatric specialities, information on 427 infants who had undergone MCUG following a first febrile UTI was prospectively recorded and their case notes reviewed. The infants were divided into two groups: Group A (117) with MCUG performed less than 4 weeks from UTI diagnosis and Group B (310) with MCUG after at least 8 weeks from diagnosis. Results: Of the 427 children, VUR was detected in 33% of those for whom MCUG was performed less than 4 weeks after UTI diagnosis and in 24% of those for whom it was performed at least 8 weeks after diagnosis. Conclusion: Neither the prevalence nor the grade of VUR in infants with a first episode of UTI is influenced by the timing of the MCUG following diagnosis. We therefore suggest that it is better to perform an MCUG as soon as possible, provided inflammation has subsided. ª 2010 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Introduction UTI is a common problem in children, and VUR, predisposing factor for recurrent pyelonephritis, is the most common anomaly of the urinary tract of infants and young children [1]. Current practice guidelines recommend MCUG to evaluate
* Corresponding author. Tel.: þ44 114 2717000; fax: þ44 114 271 7649. E-mail address: [email protected] (P. Godbole).
reflux [2,3]. The traditional interval between UTI and MCUG is 4e6 weeks to avoid false positives arising from transient reflux following inflammation and/or overestimation of ureteral dilatation during the acute infective phase [4,5]. However, the literature does not provide strong evidence to support this practice. Furthermore, recent studies in young children and infants with first UTI did not find a relationship between the presence or severity of VUR and the timing of the MCUG when this was performed later than 1 week [6,7]. More recently, the study of Doganis et al., focused on an infantile population, showed that an early MCUG (within 1 week of UTI
1477-5131/$36 ª 2010 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2010.01.008
Infantile UTI and timing of MCUG
583
diagnosis and establishment of treatment) does not result in increased false positive cystograms [8]. We have reviewed our experience of infants with a first febrile UTI looking at the timing of MCUG, aiming to find further evidence to justify an early cystogram following infantile UTI.
Methods We reviewed the records of all infants under 1 year of age presenting to a tertiary paediatric hospital between 1996 and 2006 with a first episode of febrile pyelonephritic illness. A febrile UTI was defined as pyrexia > 38 C associated with culture-proven pure growth of an organism >105 colony forming units/high-power field from an appropriately collected urine sample (clean-catch midstream urine sample or, where this was not possible, a suprapubic aspirate with ultrasound control). Our current practice is for all infants presenting with a febrile UTI to be admitted for intravenous antibiotics with subsequent chemoprophylaxis until investigations are complete. These infants undergo an ultrasound scan during admission followed by MCUG and DMSA scan as outpatients. The decision about the time scale of the MCUG was at the discretion of the attending paediatrician and paediatric radiologist; however, the traditional interval of at least 4e6 weeks after UTI was applied to the majority of the infants. We divided the patients into two groups according to the timing of the MCUG: less than 4 weeks of diagnosis of UTI (Group A) or after 8 weeks (Group B). The presence and severity of VUR were analysed in each group. None of the infants had their MCUG at exactly 4 weeks (28 days) after their UTI. Reflux was graded according to the international VUR classification [9]. Institutional ethics and clinical effectiveness committee approval was obtained for this study.
Results A total of 427 infants were eligible for enrolment. There were 258 boys (60%) and 169 girls (40%) with a median age of 5.2 months (0e12). All patients were started on prophylactic antibiotics until an MCUG was performed on an outpatient basis. One hundred and seventeen patients (Group A) had their MCUG performed less than 4 weeks after diagnosis of UTI and 310 patients (Group B) had an MCUG performed 8 weeks after infection diagnosis. Overall, 114 (27%) infants were found to have VUR as determined by MCUG. VUR was detected in 39 patients (33%) of Group A and in 75 infants (24%) of Group B (Table 1). This Table 1
Reflux and timing of MCUG. Group A
VUR No VUR Total
Group B
(MCUG < 4 weeks)
(MCUG > 8 weeks)
39 (33%) 78 (67%) 117
75 (24%) 235 (76%) 310
Chi-square Z 3.63, degrees of freedom Z 1, probability Z 0.057.
Table 2
Time between UTI diagnosis and VCUG.
No. of patients Gender Girls Boys Age Range (months) Median Prevalence of VUR Per patient (n Z 427) VUR grade I VUR grade II VUR grade III VUR grade IV VUR grade V
Group A
Group B
(MCUG < 4 weeks)
(MCUG > 8 weeks)
117 (27%)
310 (73%)
47 (40%) 70 (60%)
122 (39%) 188 (61%)
0.5e12 5.3
0.4e12 4.8
39 (33%) 5 (13%) 10 (26%) 20 (51%) 3 (8%) 1 (2%)
75 (24%) 6 (8%) 16 (21%) 39 (52%) 14 (19%) 0 (0%)
difference was not statistically significant (Chi-square Z 3.63, degrees of freedom Z 1, probability Z 0.057). Table 2 shows the characteristics of the patients and the distribution and grade of VUR in the two groups. There was no difference in severity of the VUR between the two groups (Table 2).
Discussion Our study offers further evidence that an early MCUG (within 4 weeks) following a first infantile UTI does not lead to an overestimation of the presence or grade of reflux. This study was retrospective and therefore there was no randomization of infants into early and late MCUG groups. The decision about the timing of the MCUG was at the discretion of the paediatrician or urologist. Moreover, the final timing of MCUG was dependent on the radiology department’s workload and on the attendance and availability of the patients’ parents: several missed appointments or cancellations and rescheduling were in fact the reasons why the median time for an MCUG in Group B was 9.6 weeks. Nevertheless, the sex and age distributions of infants were similar in the two groups, and the differences between the two groups concerning presence of VUR and severity were not statistically significant. The traditional practice of performing MCUG at a minimum of 4e6 weeks after UTI is based on the belief that an acute inflammatory process leads to transient reflux at the vesicoureteral junction; ureteral dilatation secondary to the effect of endotoxins released during UTI is also thought to result in over-estimation of the grade of reflux [10]. However, transient reflux and hydro-ureteronephrosis secondary to infection were found in animal studies done in the 1960s and to our knowledge have never been proved on human models [11]. Performing an MCUG sooner rather than later is safe, clinically useful and cost effective. MCUG performed soon after UTI resolution offers in fact the advantages of early diagnosis and instigation of a prompt management plan, stopping antibiotics earlier if not required, and earlier
584
G. Soccorso et al.
alleviation of parental anxiety which increases compliance. An MCUG should be performed once the infection has subsided and before the infant is discharged home; the ideal time will be within 1 week of UTI diagnosis. Randomized prospective studies are necessary to assess whether infants with their first UTI who are investigated with MCUG during the same admission (within 7 days from diagnosis) have the same outcome of those investigated at a later stage.
[3]
[4]
[5]
Conflict of interest None.
[6]
Funding source
[7]
None. [8]
Ethical approval Approved by committee.
the
clinical
effectiveness
and
audit
[9]
References [10] [1] Andrich M, Massoud M. Diagnostic imaging in the evaluation of first time urinary tract infection in infants and young children. Pediatrics 1992;90:436e41. [2] Report of a Working Group of the Research Unit Royal College of Physicians. Guidelines for the management of acute urinary
[11]
tract infection in childhood. J R Coll Physicians Lond 1991;25: 36e42. American Academy of Pediatrics Committe on Quality Improvement Subcommitte on Urinary Tract Infection. Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children. Paediatrics 1999;103:843e52. Hellerstein S. Classification of patients with urinary tract infections. In: Urinary tract infections in children. Chicago, IL: Yearbook Medical Publishers, Inc; 1982. p. 15e29. Rushton G, Belman B. Vesicoureteral reflux and renal scarring. In: Holliday M, Barratt M, Avner E, editors. Pediatric nephrology. 3rd ed. Baltimore, MD: Williams & Wilkins; 1994. p. 963e86. Mahant S, To T, Friedman J. Timing of voiding cystourethrogram in the investigation of urinary tract infections in children. J Pediatr 2001;139:568e71. Sathapornwajana P, Dissaneewate P, McNeil E, Vachvanichsanong P. Timing of voiding cystourethrogram after urinary tract infection. Arch Dis Child 2008;93:229e31. Doganis D, Mavrikou M, Delis D, Stamoyannou L, Siafas K, Sinaniotis K. Timing of voiding cystourethrography in infants with first time urinary infection. Pediatr Nephrol 2009;24: 319e22. Lebowitz RL, Olbing H, Parkkulainen KV, Smellie JM, TamminenMo ¨bius TE. International system of radiographic grading of vesicoureteric reflux. International Reflux Study in Children. Pediatr Radiol 1985;15:105e9. Hellstru ˚rild S, Wettergren B. Ureteral dila¨m M, Jodal U, Ma tation in children with febrile urinary tract infection or bacteriuria. AJR Am J Roentgenol 1987;148:483e6. Craig JC, Knight JF, Sureshkumar P, Lam A, Onikul E, Roy LP. Vesicoureteric reflux and timing of micturating cystourethrography after urinary tract infection. Arch Dis Child 1997;76:275e7.