Practice Variation and Guideline Compliance in Urologic Imaging After Initial Urinary Tract Infection in Children

To investigate practice pattern variability and drivers of imaging after febrile UTI (fUTI).

We performed a retrospective review of all children ≤6 years old presenting between 2012 and 2021 who presented in a variety of settings (outpatient, inpatient, emergency department [ED]) with diagnosis of first fUTI to a single freestanding children's hospital. Patients were excluded if no documented fever, no documented positive urine culture, or history of congenital urinary anomalies. The primary outcome was compliance with American Academy of Pediatrics guidelines regarding genitourinary (GU) imaging after the first or second fUTI. Secondary outcomes were whether patients received GU imaging and the timing of voiding cystourethrogram (VCUG). Multivariate logistic regression was performed.

Four hundred seventy-three patients met criteria with a median age of 11 months. Overall, adherence to American Academy of Pediatrics guidelines was 41%, with no significant increase in compliance over time. Sixty-four percent (306/473) underwent renal-bladder ultrasound (RBUS) after the first fUTI. Of those with abnormal RBUS, 57.1% (44/77) underwent VCUG. Six patients had a VCUG after initial fUTI but no RBUS. Of those with a second fUTI, 36.7% (18/49) underwent VCUG. Notably, 32% received no GU imaging. On multivariate analysis, compliance was associated with younger age (OR 0.98) and inpatient treatment (OR 2.97). The receipt of any imaging was associated with younger age (OR 0.98), female patients (OR 1.78), inpatient treatment (OR 4.98), and private insurance (OR 1.72).

Non-adherence to guidelines on imaging after febrile UTI remains high in the pediatric community, indicating significant potential for improvement.