• Action Statement 4a. This recommendation states that a clinician initiating treatment should base the choice of route of administration on practical considerations; oral and parenteral treatment are equally efficacious, so the choice depends on local antimicrobial sensitivity patterns and sensitivity testing of the isolated uropathogen. This "strong recommendation" is based on level A evidence.
• Action Statement 4b. This "recommendation," based on level B evidence, states that treatment duration should be 7-14 days.
Most children can be treated orally, and although no data comparing 7-, 10-, and 14-day regimens were available, evidence does exist showing that courses of 1-3 days are inferior. Therefore, the minimal duration of treatment should be 7 days, the subcommittee said.
• Action Statement 5. This recommendation addresses the need for renal and bladder ultrasonography (RBUS) in all febrile infants with UTIs. Level C evidence resulted in this "recommendation."
"The purpose of RBUS is to detect anatomic abnormalities that require further evaluation, such as additional imaging or urologic consultation. RBUS also provides an evaluation of the renal parenchyma and an assessment of renal size that can be used to monitor renal growth" they wrote, adding that RBUS is recommended during the first 2 days of treatment unless substantial clinical improvement is demonstrated before that. In those cases, imaging should not occur early during acute infection, as the findings may be misleading.
• Action Statement 6a. This recommendation notes that VCUG should not be used routinely after a first febrile UTI, but should be reserved for use if RBUS reveals hydronephrosis, scarring, or other findings suggestive of high-grade VUR or obstructive uropathy. It may also be used in "other atypical or complex clinical circumstances." Level B evidence supports this "recommendation."
• Action Statement 6b states that further evaluation should be conducted if there is a recurrence of febrile UTI. This statement is supported by level X evidence, indicating that the "recommendation" is based on "exceptional situations where validating studies cannot be performed and there is a clear preponderance of benefit or harm."
Specifically, this statement reflects the fact that studies in recent years have brought into question the value of prophylaxis for preventing recurrent UTI, as well as the rationale for performing VCUG routinely after an initial febrile UTI.
The previous guideline included strong encouragement of imaging studies despite insufficient evidence supporting routine VCUG, but the "position of the current subcommittee reflects the new evidence demonstrating antimicrobial prophylaxis not to be effective as presumed previously. Moreover, prompt diagnosis and effective treatment of a febrile UTI recurrence may be of greater importance regardless of whether VUR is present or the child is receiving antimicrobial prophylaxis," they wrote.
• Action Statement 7. This recommendation states that after confirmation of a UTI, the clinician should instruct parents or guardians to seek prompt medical evaluations – ideally within 48 hours – if febrile illness recurs.
This is to ensure that recent infections are detected and treated promptly, they noted. Level C evidence supports this "recommendation."
"Early treatment limits renal damage better than late treatment, and the risk of renal scarring increases as the number of recurrences increases. For these reasons, all infants who have sustained a febrile UTI should have a urine specimen obtained at the onset of subsequent febrile illnesses so that UTI can be diagnosed and treated promptly," they wrote.
This updated guideline focuses on diagnosis and management of an initial UTI in children aged 2-24 months with no obvious neurologic or anatomic abnormalities known to be associated with recurrent UTI or renal damage. Fever for the purpose of the guideline was defined as a temperature of at least 100.4° F.
In developing the update, the subcommittee performed literature searches, including surveillance of Medline-listed literature over the past 10 years, and – in light of the increasing evidence questioning the value of antimicrobial prophylaxis to prevent recurrent febrile UTI in children with VUR – they also performed a systematic review of literature on the effectiveness of prophylactic antimicrobial therapy to prevent recurrent febrile UTI in this population. Using data from six randomized controlled trials for which raw data on infants aged 2-24 months were available, they also performed a meta-analysis addressing the effectiveness of prophylactic antimicrobial therapy. The findings are published in the companion technical report (Pediatrics 2011;128:e749–e770 [doi:10.1542/peds.2011-1332).
The authors of the guideline stressed that their recommendations do not represent standard of care or indicate an exclusive course of treatment, but rather are intended to assist clinicians in decision-making.
In his accompanying editorial, Dr. Newman praised many aspects of the updated guideline, but also highlighted some instances where he believes "alternative recommendations are supported by available evidence."