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An audit of RCP guidelines on DMSA scanning after urinary tract infection
1University Hospital of Wales, University of Wales College of Medicine, Heath Park, Cardiff CF14 4XN, UK.
Insights
Dimercaptosuccinic acid (DMSA) scans may be unnecessary for children over one year with simple urinary tract infections (UTIs). Investigations showed a low yield and minimal impact on management, suggesting DMSA scans could be omitted in this group.
Area of Science:
- Pediatric Nephrology
- Diagnostic Imaging
- Infectious Diseases
Background:
- Urinary tract infections (UTIs) are common in children, necessitating appropriate diagnostic imaging.
- National guidelines exist for investigating pediatric UTIs, but their impact on management requires assessment.
- The utility and potential harms of imaging investigations like DMSA scans in children with UTI are debated.
Purpose of the Study:
- To evaluate the outcomes of imaging investigations in children diagnosed with UTI.
- To compare current imaging practices against established national guidelines.
- To determine the impact of these investigations on clinical management decisions.
Main Methods:
- A retrospective review was conducted on 164 children (aged 0-12 years) with confirmed UTI.
- Children with prior investigations for urological anomalies or major congenital issues were excluded.
- Data on diagnostic imaging (ultrasound, DMSA scan) and management were analyzed.
Main Results:
- Prevalence of ultrasound-detected dilatation was 8%, renal scarring on DMSA scan was 11%, and vesicoureteric reflux (VUR) was 34% when following guidelines.
- In children aged 1-6 years, renal scarring prevalence was significantly higher in inpatients (33%) compared to those treated at home (2%).
- Diagnosis at home occurred in 23% of infants and 76% of older children.
Conclusions:
- DMSA scanning may be omitted in children over one year with a first simple UTI not requiring hospitalization, due to low yield and impact.
- The expense, radiation exposure, and psychological distress associated with DMSA scans warrant reconsideration for this patient group.
- Under-diagnosis of UTI in infants presenting to primary care may be occurring, highlighting a need for improved detection.
Aim:
To assess the outcome of imaging investigations carried out in children with urinary tract infection (UTI), to compare the investigations with national guidelines, and to assess the impact on management.
Methods:
Retrospective review of inpatients and outpatients, aged 0-12 years, referred to the University Hospital of Wales Healthcare Trust between February 1997 and January 1998 with UTI. All children without bacterial evidence of UTI and children previously investigated for antenatal urological anomalies, major congenital anomalies, or UTI were excluded.
Results:
A total of 164 children (51 boys, 113 girls) were included. Thirteen of 56 infants (23%) and 82/108 older children (76%) were diagnosed at home over one year. The prevalence of dilatation on ultrasound was 8%, renal scarring on dimercaptosuccinic acid (DMSA) scan was 11%, and vesicoureteric reflux (VUR) was 34% when investigations were carried out following guidelines published by the Royal College of Physicians. In children aged 1-6 years, the prevalence of scarring was 1/54 (2%) in those treated at home and 6/18 (33%) in inpatients.
Conclusion:
The low yield of positive results and lack of evidence of impact on management indicate that DMSA scanning, with all the implications of isotope exposure, intravenous injection, staff time, psychological trauma, and expense, could be omitted in children over 1 year with first simple UTI not sufficiently ill to be admitted to hospital. The low rate of detection of UTI in primary care in infants may represent under diagnosis.