This rule combines clinical (family history of uropathology, male gender, young age), biological (raised C reactive protein), and radiological (urinary tract dilation on renal ultrasound) predictors in a score, and was deemed to provide 100% sensitivity to decide when to obtain a Voiding cystourethrogram (VCUG) in children who have had a first febrile UTI.

A retrospective hospital based cohort study included all children, 1 month to 4 years old, with a first febrile urinary tract infection. The sensitivities and specificities of the rule at the two previously proposed score thresholds (< or =0 and < or =5) to predict respectively, all-grade or grade > or =3 VUR, were calculated. A total of 149 children were included. VUR prevalence was 25%. The rule yielded 100% sensitivity and 3% specificity for all-grade VUR, and 93% sensitivity and 13% specificity for grade > or =3 VUR.

Based on this study, their hypothesis that this rule would work is wrong. The reproducibility was poor and probably have little if any role in the clinical management of children with febrile urinary tract infections.

Dr. Barry Kogan from Albany, New York, USA, gave an editorial comment. In summary he stated the current study population did not support the use of the decision-rule. In order not to miss a positive VCUG, only 3 of the 143 patients would have been excluded. Nineteen could have been excluded if the clinician would be willing to miss 8% of the refluxing patients, including 1 of the 14 with at least grade 3/5 reflux. Also, VCUGs themselves are only about 80% sensitive. Therefore, the reported analysis is likely an overly positive estimate of the benefits of the decision-rule. He goes on to state that some believe it is possible that diagnosing reflux may have no value, although he does not agree with that statement. Furthermore, according to some, giving temporary prophylactic antibiotics to all patients with febrile UTIs may be helpful, while others state that prophylactic antibiotics themselves are of no value. He adds by stating if all this is true then, "why bother diagnosing reflux?"

I feel the answer to UTIs is we just don't know. It will probably turn out to be multifactorial with dilating reflux playing a role, but who knows how much of a role. We have to take into account bacterial virulence, immunology, dysfunctional voiding, and constipation as being more important than reflux itself. Nonetheless, I agree with Dr Kogan that "most clinicians still want to diagnose reflux. Therefore, a decision-rule like the one proposed would be of great value. At this time, unfortunately, none exists."

Arch Dis Child. 91: 241-244, 2006

Written by Pasquale Casale, MD, a Contributing Editor with UroToday.

Please log-in or register in order to submit comments.

Powered by AkoComment!