Section on Urology response to new Guidelines for the diagnosis and management of UTI.

This commentary provides a summarized response regarding the newly published American Academy of Pediatrics Guidelines on urinary tract infection (UTI) diagnosis and evaluation from the Section on Urology of the American Academy of Pediatrics. Although the section supports some aspects of the guidelines, the new recommendation not to perform a voiding cystourethrogram (VCUG) after a first febrile UTI is not supported. The section expresses significant concern that the recommendation is based on a flawed interpretation of limited data and that this stands to potentially harm significant numbers of children because of delayed diagnosis of harmful urinary tract conditions. The Section of Urology of the American Academy of Pediatrics enthusiastically supports many aspects of the new Guideline on UTI evaluation and management. Specifically, when faced with a febrile sick child (aged 2 months to 2 years), UTI should be considered a significant cause and a urine culture be obtained by urethral catheterization or suprapubic aspiration. Bag urine cultures are not recommended. Antibiotic therapy should not be started without a urine culture. The presence of$50 000 CFU/mL is now considered to be diagnostic of UTI, and oral or parenteral antibiotic therapy, tailored to bacterial sensitivity and clinical efficacy, is adequate initial therapy. Under the 1999 Guideline, after a culture-proven febrile UTI, the recommended workup included a renal and bladder ultrasound (RBUS) and a VCUG. The new Guidelines recommend that an RBUS be performed but that a VCUG not be done if the RBUS is normal. This represents a paradigm shift in the evaluation of children with a febrile UTI. We agree that an ultrasound should be performed in a child after a febrile UTI; we do not agree that a VCUG should not be routinely performed. The recommendation is based on several recent studies comparing antibiotic prophylaxis with no prophylaxis in children with vesicoureteral reflux (VUR), with the conclusion that it is not worth making the diagnosis of VUR. We believe that these conclusions are premature and represent a misinterpretation of the data presented. The studies cited are concerning in several ways. The Guidelines stress repeatedly that proper urine samples be obtained by urethral catheterization or suprapubic aspiration to accurately diagnose a UTI. Yet the articles cited depend heavily on data from bag specimens. The circumcision status for boys is unaccounted for; this is important because of the well-known relationship between febrile UTI and being uncircumcised in boys ,1 year of age. It is not unexpected that uncircumcised boys in these cohorts would have UTIs, whether or not they were on prophylaxis. In addition, bagged specimens are particularly inaccurate in these boys. There is no AUTHORS: Julian Wan, MD,a Steven J. Skoog, MD,b William C. Hulbert, MD,c Anthony J. Casale, MD,d Saul P. Greenfield, MD,e Earl Y. Cheng, MD,f and Craig A. Peters, MD,g on behalf of the Executive Committee, Section on Urology, American Academy of Pediatrics aDepartment of Urology, University of Michigan, Ann Arbor, Michigan; bDivision of Urology, Oregon Health and Science University, Portland, Oregon; cDivision of Pediatric Urology, University of Rochester, Rochester, New York; dKosair Children’s Hospital, Louisville, Kentucky; eDivision of Pediatric Urology, Women and Children’s Hospital of Buffalo, State University of New York at Buffalo School of Medicine and Biomedical Science, Buffalo, New York; fDivision of Urology, Children’s Memorial Hospital, Northwestern University, Chicago, Illinois; and gDivision of Surgical Innovation, Children’s National, George Washington University, Washington, District of Columbia