HM14 Special Report: Rationale and Review of the New Guidelines for First Febrile UTI

Presenter: Maria Finnell, M.D., a leading member of the American Academy of Pediatrics Subcommittee on Urinary Tract Infection

Summary: Dr. Finnell summarized the recent changes in diagnosis and management of pediatric urinary tract infections (UTIs). The 2011 publication of “Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months” was an update of the 1999 technical report of UTI management. Dr. Finnell reviewed the difference between evidence based and eminence based recommendations. She stated the term “recommendations” was changed to “key action statements” in a new explicit reporting format. Aggregate quality of the evidence is presented in the report in an effort to keep statements transparent.

The process of updating the new guideline was based on the U.S. Preventive Services Task Force approach using a stepwise process. For the revised UTI recommendations the steps were narrowed to:

• Risk of having infection
• Making a diagnosis
• Treatment of UTI
• Identification and Evaluation for high risk conditions

Patient population for this guideline includes initial UTI in child age 2 months to 2 years of age. Patients with neurological conditions or recurrent UTI or renal damage are excluded. Dr. Finnell reviewed action statements for the revised guidelines. A summary of some of these statements:

1. If antibiotics are going to be administered, a urine specimen should be collected by catheterization or suprapubic aspiration (SPA).
2. Assessment of UTI risk should be performed in a febrile child with no source of infection. The guideline cites specific data for risk. If the likelihood is low then it is reasonable to follow the child clinically without a urine specimen. If the likelihood of a UTI is high then a urine specimen should be obtained.
3. To establish the diagnosis of UTI, clinicians should require both urinalysis results that suggest infection and the presence of at least 50,000 colony-forming units (CFUs) per mL of a uropathogen cultured from a urine specimen obtained through catheterization or SPA.
4. Oral and parenteral routes are equally efficacious.
5. The clinician should choose 7-14 days as duration of treatment.
6. Febrile infants with UTIs should undergo renal and bladder ultrasonography.
7. VCUG should not be routinely performed after first UTI if ultrasound is normal.

Dr. Finnell also discussed controversy of not performing a VCUG after a first febrile UTI, as was recommended in the 1999 technical report. She summarized that about 100 children would need to undergo one UTI in the first year. She also reviewed limitations of any guidelines. New studies will assist in monitoring population changes with the revised guideline.

Key Takeaways:

• Understand the evidence and limitations used for all clinical guidelines that you use in practice.
• The updated 2011 guideline for evaluation and management of first febrile UTIs uses risk stratification as an initial approach.
• A major change in the updated 2011 guideline for evaluation and management of first febrile UTIs is that a VCUG is not required for initial evaluation.

Dr. Hale is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston.

Reference:

Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months. Pediatrics. 2011;128(3).