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Acute urinary tract infection--evaluation and treatment
1Section of Pediatric Nephrology, The Children's Mercy Hospital, The University of Missouri School of Medicine at Kansas City, Missouri 64108, USA. shellers@cmh.edu
Insights
Urinary tract infections in children are evolving. New evidence suggests nonreflux nephropathy is as common as reflux nephropathy, questioning the need for routine imaging and antibiotic suppression for vesicoureteric reflux.
Area of Science:
- Pediatric Nephrology
- Infectious Diseases
- Urology
Background:
- Management of pediatric urinary tract infections (UTIs) is shifting due to new evidence and technology.
- Uncircumcised male infants face a higher UTI risk, with varying circumcision rates globally.
- Vesicoureteric reflux (VUR) is no longer considered the sole major risk factor for renal damage in UTIs; nonreflux nephropathy is now recognized.
Purpose of the Study:
- To review current evidence and technological impacts on UTI evaluation and management in infants and children.
- To discuss the changing understanding of risk factors for acquired renal damage from UTIs.
- To evaluate the utility of biochemical markers and imaging in identifying renal damage.
Main Methods:
- Review of evidence-based studies and technological advancements in pediatric UTI management.
- Analysis of data on risk factors for renal damage, including VUR and nonreflux nephropathy.
- Evaluation of procalcitonin as a biomarker for kidney damage risk and dimercaptosuccinic acid scintigraphy as a reference standard.
Main Results:
- The role of VUR as the primary cause of acquired renal injury secondary to UTI is being re-evaluated.
- Nonreflux nephropathy occurs with similar frequency to reflux nephropathy.
- Procalcitonin shows promise as a biochemical tool for assessing kidney damage risk.
Conclusions:
- The traditional view of VUR as the main driver of renal injury in UTIs is outdated.
- The necessity of imaging studies for VUR detection and suppressive antibiotics for VUR is now questioned.
- While evidence supports antibiotic therapy for UTIs, guidance for imaging selection in febrile infants is lacking.
Purpose Of Review:
The evaluation and management of urinary tract infections in infants and children is undergoing changes due to the impact of evidence-based studies and new technology.
Recent Findings:
The uncircumcised male infant is at increased risk for a urinary tract infection, but there is marked difference in the frequency of circumcision carried out to lower the risk of infection in the United States compared with Europe. Commentaries presenting different interpretations of the current data make for interesting reading and present the many sides of this issue. Vesicoureteric reflux, previously viewed as the major risk factor for acquired renal damage, now shares this role with nonreflux nephropathy. Procalcitonin has been evaluated as a biochemical tool to identify patients at risk for kidney damage, with dimercaptosuccinic acid scintigraphy as the reference method to detect renal scarring.
Summary:
The previously accepted concept that vesicoureteric reflux as detected radiologically is almost always the key factor in acquired renal injury secondary to a urinary tract infection is no longer accepted. Current studies show that nonreflux nephropathy occurs as often as reflux nephropathy. There is now a question of the value of imaging studies designed to identify vesicoureteric reflux and of the use of suppressive antibiotics for vesicoureteric reflux. There exist useful evidence-based studies for antibiotic therapy for upper and lower tract urinary tract infections, but no such data are available for guidance in selecting imaging studies for the infant or child with a first febrile urinary tract infection.
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