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Objective: To assess the effect of the duration of fever after the initiation of treatment (FAT) of febrile urinary tract infections (UTI) on the development of permanent renal lesions based on dimercaptosuccinic acid (DMSA) scintigraphy findings. To evaluate the FAT contribution to permanent renal lesion formation in relation to fever before treatment initiation (FBT), the presence of vesicourinary reflux (VUR), age and severity of infection.Methods: The inpatient records of 148 children (median age: 2.4 months (11 days to 24 months)) with a first episode of UTI during a 3-year period were analysed. DMSA findings, and clinical and laboratory parameters were evaluated.Results: Among the study population, 34/148 (22.97%) children had permanent renal lesions on the DMSA scan 6 months after a single episode of UTI. Twenty-three children (15.5%) had mild, 10 (6.7%) had moderate and 1 (0.6%) child had severe lesions on the DMSA. FAT prolongation >/48 hours was associated with older age (p=0.01) and increased absolute neutrophil count (p=0.042). The likelihood of lesions was significantly increased when FAT was ≥48 hours (R2=0.043, p=0.021). On multiple regression analysis, with the addition of FBT>/72 hours (0.022), the presence of VUR (p<0.001), C-reactive protein (p=0.027) and age (p=0.031), the effect of FAT on lesion development disappeared (p=0.15).Conclusions: Prolongation of FAT≥48 hours of febrile UTI in children <2 years significantly contributes to the development of permanent renal lesions. However, delay in treatment initiation >/72 hours, the presence of VUR, older age and infection severity seem to be more significant predictors of the development of renal lesions. [ABSTRACT FROM AUTHOR]

The histories and imaging results are presented in 10 children in whom errors had been made in the interpretation of early investigations. Ultrasonography may not detect either vesicoureteric reflux (VUR) or renal scars or inflammation. The reduced nephrogram or renal swelling following a first attack of acute pyelonephritis may not be recognised without renal measurement on an intravenous urogram. Renal scarring may be diagnosed incorrectly on the basis of functional defects of isotope uptake on a technetium 99m-dimercaptosuccinic acid study. In the absence of VUR, the micturating cystogram will not visualise the kidneys. [ABSTRACT FROM AUTHOR]

The optimal regimen for investigating children with urinary tract infection (UTI) remains uncertain. Ultrasonography, contrast micturating cystourethrography (MCU), intravenous urography (IVU), and technetium-99m dimercaptosuccinic acid (DMSA) studies were performed in 58 children with UTI under 14 years of age attending two teaching hospitals and the results compared. All four investigations were normal in 12 children. In 36 with vesicoureteric reflux (VUR) on MCU, dilatation was reported on ultrasonography in eight children. Radiological renal scarring was seen in 20 children; it was suspected on ultrasonography in nine, with dilatation alone in four, and a normal report in seven. Duplex kidneys identified on IVU were unrecognised on ultrasonography or DMSA studies; ultrasonography showed no change corresponding to presumed acute defects on DMSA studies that later resolved. Disparities were observed at all ages. This study suggests that ultrasonography is unreliable in detecting VUR, renal scarring, or inflammatory change and, alone, is inadequate for investigating UTI in children. [ABSTRACT FROM AUTHOR]

Objective: To compare the childhood urinary tract infection (UTI) guidelines from the Royal College of Physicians (RCP) in 1991 and from National Institute of Health and Care Excellence (NICE) (CG54) in 2007 by measuring their efficiency at detecting urinary tract abnormalities., Design: Children with UTIs within the Newcastle Primary Care Trust (population 70,800 children) were referred and imaged according to the RCP guidelines during 2008, and these were compared to the activity that would have been undertaken if we had implemented the CG54 guidelines, including following them through 2011 to identify those with recurrent UTIs., Main Outcome Measures: The numbers of children imaged, the imaging burden and efficiency, and urinary tract abnormalities detected by each guideline., Results: Fewer children would have been imaged by CG54 than RCP (150 vs 427), but its sensitivity was lower, at 44% for detecting scarring, 10% for identifying vesicoureteric reflux and 40% for other abnormalities. Overall, it would have only detected one-quarter of the abnormal cases (8 vs 32) and would have missed five of nine children with scarring, including three with multiple lesions and one with renal impairment. Imposing an age restriction of <8 years to the RCP guidelines would reduce its screening rate by 20% and still detect 90% of the abnormalities., Interpretation: The CG54 guidelines do not alter the imaging efficiency compared to the RCP guidelines, but they are considerably less sensitive.

Objective: To test whether active management of urinary tract infections (UTI) in young children by general practitioners can reduce kidney scarring rates., Design: A comparison of two audits in Newcastle, of children aged <8 years, presenting with UTIs ; a retrospective audit of conventional management during 1992-1995 (1990s) versus a prospective audit of direct access management during 2004-2011 (2000s)., Main Outcome Measures: Kidney scarring rates, and their relationship with time-to-treat., Results: Children with a first UTI in the 2000s compared to those in the 1990s, were referred younger, were half as likely to have a renal scar (girls OR 0.47, 95% CI 0.29 to 0.76; boys 0.35, 0.16 to 0.81), and were about 12 times more likely to have vesicoureteric reflux without scarring (girls 11.9, 4.3 to 33.5; boys 14.4, 4.3 to 47.6). In the 2000s, general practitioners treated about half the children at first consultation. Children who were treated within 3 days of their symptoms starting were one-third as likely to scar as those whose symptoms lasted longer (0.33, 0.12 to 0.72)., Interpretation: Most kidney defects seen in children after UTIs, are acquired scars, and in Newcastle, active management in primary care has halved this rate.