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Conflicting views of physicians and surgeons concerning pediatric urinary tract infection: a comparative review
Ian K Hewitt1, Derek J Roebuck2,3, Giovanni Montini4,5
1Department of Pediatric Nephrology, Perth Children's Hospital, Nedlands, 6009, Australia.
Insights
Pediatricians favor conservative management for a child's first febrile urinary tract infection (UTI), while surgeons prefer aggressive investigation and intervention to prevent kidney damage. This divergence can confuse caregivers.
Area of Science:
- Pediatric Nephrology
- Pediatric Urology
- Infectious Diseases
Background:
- First febrile urinary tract infection (UTI) is a common pediatric condition with evolving management strategies.
- Understanding the differing approaches between pediatricians and surgeons is crucial for optimizing care.
- Divergent management pathways can create confusion for parents and caregivers.
Approach:
- A comprehensive literature search was performed for studies published between 2011 and 2021.
- Included studies focused on the investigation and management of first febrile UTIs in children.
- Papers were analyzed based on recommendations for imaging (ultrasound, VCUG), antibiotic prophylaxis, and surgical intervention for detected vesicoureteral reflux (VUR).
Key Points:
- Pediatricians generally advocate for less invasive diagnostic imaging and a "watchful-waiting" approach.
- Surgeons tend to recommend more extensive imaging to detect VUR and are more inclined towards antibiotic prophylaxis and surgical correction.
- Combined authorship papers showed intermediate management recommendations.
Conclusions:
- Significant differences exist in the investigation and management of pediatric febrile UTIs between pediatricians and surgeons.
- Pediatricians prioritize minimizing intervention, while surgeons focus on early detection and aggressive treatment of VUR.
- The contrasting approaches highlight a need for clearer, unified guidelines to ensure consistent patient care.
Background:
A first febrile urinary tract infection (UTI) is a common condition in children, and pathways of management have evolved over time.
Objective:
To determine the extent to which pediatricians and surgeons differ in their investigation and management of a first febrile UTI, and to evaluate the justifications for any divergence of approach.
Materials And Methods:
A literature search was conducted for papers addressing investigation and/or management following a first febrile UTI in children published between 2011 and 2021. Searches were conducted on Medline, Embase, and the Cochrane Controlled Trials Register. To be eligible for inclusion, a paper was required to provide recommendations on one or more of the following: ultrasound (US) and voiding cystourethrogram (VCUG), the need for continuous antibiotic prophylaxis and surgery when vesicoureteral reflux (VUR) was detected. The authorship required at least one pediatrician or surgeon. Authorship was categorized as medical, surgical, or combined.
Results:
Pediatricians advocated less imaging and intervention and were more inclined to adopt a "watchful-waiting" approach, confident that any significant abnormality, grades IV-V VUR in particular, should be detected following a second febrile UTI. In contrast, surgeons were more likely to recommend imaging to detect VUR (p<0.00001), and antibiotic prophylaxis (p<0.001) and/or surgical correction (p=0.004) if it was detected, concerned that any delay in diagnosis and treatment could place the child at risk of kidney damage. Papers with combined authorship displayed intermediate results.
Conclusion:
There are two distinct directions in the literature regarding the investigation of an uncomplicated first febrile UTI in a child. In general, when presented with a first febrile UTI in a child, physicians recommend fewer investigations and less treatment, in contrast to surgeons who advocate extensive investigation and aggressive intervention in the event that imaging detects an abnormality. This has the potential to confuse the carers of affected children.
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