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Controversy exists regarding the best approach for evaluating children after a first febrile urinary tract infection (UTI). Some professional groups advocate selective imaging, while others promote renal ultrasonography (US) and either dimercaptosuccinic acid (DMSA) scintigraphy or voiding cystourethrography (VCUG) in all children younger than 2 years with a first UTI. Further debate exists about whether US, DMSA scan, or both can detect vesicoureteral reflux (VUR). Investigators in Italy compared the accuracy of DMSA scans and US for detecting reflux in 296 children (age range, 0.5–23 months; 56% males) with first febrile UTI.
On the basis of VCUG (the gold standard), 46 children had dilating (grades 3 and 4) VUR and 25 had severe (grade 4 or 5) VUR. Abnormal results on US, DMSA scan, or both were not highly sensitive or specific for detecting severe reflux disease (see Table). Four children with severe reflux had both normal US and DMSA scans.
Fouzas S et al. DMSA scan for revealing vesicoureteral reflux in young children with urinary tract infection. Pediatrics 2010 Sep; 126:e513.
Comment
Although it is unclear whether radiologists in this study were aware of VCUG results when they interpreted the US and DMSA studies, this study suggests that US and DMSA studies, alone or combined, can miss severe VUR in children. Recent studies suggest that antibiotic prophylaxis following a diagnosis of UTI in children does not alter the incidence of future renal scars (JW Pediatr Adolesc Med Jun 11 2008 and JW Pediatr Adolesc Med Oct 28 2009). However, most children enrolled in those studies had grade 1, 2, or 3 VUR. Thus, I do not believe that prophylactic antibiotics are indicated in children with mild reflux disease. Because few data are available in children with grades 4 and 5 reflux, children with severe disease should probably receive prophylaxis.