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Practice Variation and Guideline Compliance in Urologic Imaging After Initial Urinary Tract Infection in Children
Hsin-Hsiao Scott Wang1, Anh-Dao Cheng2, Jiali Cai1
1Department of Urology, Boston Children's Hospital, Boston, MA.
Insights
Pediatric febrile urinary tract infections (fUTI) show low adherence to imaging guidelines. Many children do not receive recommended genitourinary (GU) imaging, highlighting a need for improved practice patterns.
Area of Science:
- Pediatric Nephrology
- Pediatric Urology
- Infectious Diseases
Background:
- Febrile urinary tract infections (fUTI) are common in children.
- Genitourinary (GU) imaging is recommended by guidelines after fUTI to detect anomalies.
- Practice patterns for GU imaging after fUTI can vary significantly.
Purpose of the Study:
- To investigate practice pattern variability in GU imaging after fUTI in children.
- To identify factors influencing the decision to perform imaging after fUTI.
- To assess adherence to American Academy of Pediatrics (AAP) guidelines for GU imaging.
Main Methods:
- Retrospective review of children ≤6 years old with first fUTI (2012-2021).
- Exclusion criteria: no documented fever, no positive urine culture, or history of congenital urinary anomalies.
- Primary outcome: AAP guideline compliance for GU imaging; secondary outcomes: imaging receipt and voiding cystourethrogram (VCUG) timing. Multivariate logistic regression used.
Main Results:
- 473 children met criteria; median age 11 months. Guideline adherence was 41%, with no significant increase over time.
- 64% received renal-bladder ultrasound (RBUS); 57.1% of those with abnormal RBUS had a VCUG.
- 32% received no GU imaging. Younger age, inpatient treatment, female sex, and private insurance were associated with receiving imaging.
Conclusions:
- High rates of non-adherence to AAP imaging guidelines persist after pediatric fUTI.
- Significant opportunities exist to improve the appropriate use of GU imaging in children with fUTI.
- Practice patterns require optimization to align with evidence-based recommendations.
Objective:
To investigate practice pattern variability and drivers of imaging after febrile UTI (fUTI).
Methods:
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.
Results:
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).
Conclusion:
Non-adherence to guidelines on imaging after febrile UTI remains high in the pediatric community, indicating significant potential for improvement.
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