AAP Updates UTI Guidelines for Febrile Infants

Antimicrobial prophylaxis to prevent febrile recurrent urinary tract infection in infants aged 2 months to 2 years without vesicoureteral reflux or with grade I to IV VUR is not supported by currently available data, and therefore voiding cystourethrography to detect VUR should no longer be used routinely after a first UTI in this population, according to a newly updated American Academy of Pediatrics practice guideline.

The update – the first since 1999 to the guideline regarding the diagnosis and management of the initial UTI in febrile infants and young children – is published in the Aug. 29 issue of Pediatrics (2011;128:595-610 [doi:10.1542/peds.2011-1330]).

The previous guideline included strong encouragement of imaging studies despite insufficient evidence supporting a routine voiding cystourethrogram (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," according to the AAP Subcommittee on Urinary Tract Infection, which authored the updated guideline.

The update, which is intended for use in various clinical settings including offices, hospitals, and emergency departments for the diagnosis and management of the approximately 5% of children in this age group who are affected by UTIs, is based in large part on new data regarding imaging and diagnostic criteria in this population.

It also includes changes as to which children should undergo urine testing, how the sample should be obtained, and how treatment and follow-up should be conducted in those found to have a UTI, according to lead author Dr. Kenneth B. Roberts of Greensboro, N.C., and his subcommittee colleagues.

The "long-awaited update" provides an "exceptionally evidence-based guideline that differs in important ways from the 1999 guidelines and sets a high standard for transparency and scholarship," Dr. Thomas B. Newman of the University of California, San Francisco, wrote in an accompanying editorial (Pediatrics 2011;128:572-75 [doi:10.1542/peds.2011-1818]).

Dr. Newman also said that the guideline and a technical report containing the data on which the recommendations are based represent "a significant advance."

The guideline includes seven recommendations or action statements:

• Action Statement 1. It calls for obtaining a urine specimen for both culture and urinalysis prior to administration of an antimicrobial agent in infants with no apparent source for their fever, and in whom the clinician decides antimicrobial therapy should be administered due to ill appearance or another pressing reason. Since they assert that the diagnosis of UTI cannot be reliably established through culture of urine collected in a bag, the subcommittee says the specimen should be obtained through catheterization or suprapubic aspirate (SPA). The evidence quality for this "strong recommendation" was level A, meaning it is based on well-designed randomized controlled trials or diagnostic studies of relevant populations.

Although catheterization is invasive, the subcommittee determined that the risks of this approach are outweighed by the potential benefit of diagnosing a UTI and treating it appropriately before renal scarring occurs, and, conversely, by avoiding overtreatment and unnecessary and expensive imaging.

• Action Statements 2a and 2b. These also represent "strong recommendations" based on level A evidence, but address those febrile infants who the clinician does not feel require immediate antimicrobial therapy. In these infants, the clinician should assess whether the likelihood of UTI is low or high. Those with a low likelihood of UTI (such as those with another obvious infection, which reduces the likelihood of UTI) can undergo clinical follow-up monitoring without testing; those not in a low-risk group (such as girls and uncircumcised boys, who have a higher risk for UTI) can be managed either by obtaining a urine specimen via catheterization or SPA for culture and urinalysis, or by the most convenient means for urinalysis. If the urinalysis results suggest a UTI, a specimen should then be obtained by catheterization or SPA for culture.

A negative urinalysis, however, suggests it is reasonable to monitor the clinical course without initiating antimicrobial therapy.

• Action Statement 3. This also addresses UTI diagnosis, and states that clinicians should require both urinalysis results that suggest infection (pyuria and/or bacteriuria) and the presence of at least 50,000 colony-forming units per milliliter of a uropathogen cultured from a specimen obtained via catheterization or SPA. Unlike the first two action statements, this one is based on observational studies, and thus is considered level C evidence and represents a "recommendation" rather than a "strong recommendation."

"These criteria reduce the likelihood of overdiagnosis of UTI in infants with asymptomatic bacteriuria or contaminated specimens," the subcommittee wrote.

• 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."

For example, while he agrees that the recommendation on selective urine testing based on the prior probability of UTI is "an important improvement," and he lauded the subcommittee’s job summarizing the factors that determine that probability, he questioned the assertion that the threshold probability for urine testing is below 3%, and proposed that until this is proven, the decision to test should be individualized.

Additionally, while he said he is "glad the new guideline continues to offer the option of obtaining urine for urinalyses noninvasively," he also said he is not convinced that the bag urine can never be used for culture. "If the urinalysis is used to select urine for culture, the prior probability may sometimes be in a range where the bag culture will be useful," he explained.

Despite these and other concerns addressed by Dr. Newman, he saluted the authors and noted that the updated guideline should prove helpful to clinicians and families dealing with this common problem.

Members of the subcommittee that developed this guideline included individuals with expertise in the fields of academic general pediatrics, epidemiology and informatics, pediatric infectious disease, pediatric nephrology, pediatric practice, pediatric radiology, and pediatric urology. The AAP funded the development of the guidelines; none of the subcommittee members had financial conflicts of interest. Dr. Newman also had no financial conflicts to report.

Antimicrobial prophylaxis to prevent febrile recurrent urinary tract infection in infants aged 2 months to 2 years without vesicoureteral reflux or with grade I to IV VUR is not supported by currently available data, and therefore voiding cystourethrography to detect VUR should no longer be used routinely after a first UTI in this population, according to a newly updated American Academy of Pediatrics practice guideline.

The update – the first since 1999 to the guideline regarding the diagnosis and management of the initial UTI in febrile infants and young children – is published in the Aug. 29 issue of Pediatrics (2011;128:595-610 [doi:10.1542/peds.2011-1330]).

The previous guideline included strong encouragement of imaging studies despite insufficient evidence supporting a routine voiding cystourethrogram (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," according to the AAP Subcommittee on Urinary Tract Infection, which authored the updated guideline.

The update, which is intended for use in various clinical settings including offices, hospitals, and emergency departments for the diagnosis and management of the approximately 5% of children in this age group who are affected by UTIs, is based in large part on new data regarding imaging and diagnostic criteria in this population.

It also includes changes as to which children should undergo urine testing, how the sample should be obtained, and how treatment and follow-up should be conducted in those found to have a UTI, according to lead author Dr. Kenneth B. Roberts of Greensboro, N.C., and his subcommittee colleagues.

The "long-awaited update" provides an "exceptionally evidence-based guideline that differs in important ways from the 1999 guidelines and sets a high standard for transparency and scholarship," Dr. Thomas B. Newman of the University of California, San Francisco, wrote in an accompanying editorial (Pediatrics 2011;128:572-75 [doi:10.1542/peds.2011-1818]).

Dr. Newman also said that the guideline and a technical report containing the data on which the recommendations are based represent "a significant advance."

The guideline includes seven recommendations or action statements:

• Action Statement 1. It calls for obtaining a urine specimen for both culture and urinalysis prior to administration of an antimicrobial agent in infants with no apparent source for their fever, and in whom the clinician decides antimicrobial therapy should be administered due to ill appearance or another pressing reason. Since they assert that the diagnosis of UTI cannot be reliably established through culture of urine collected in a bag, the subcommittee says the specimen should be obtained through catheterization or suprapubic aspirate (SPA). The evidence quality for this "strong recommendation" was level A, meaning it is based on well-designed randomized controlled trials or diagnostic studies of relevant populations.

Although catheterization is invasive, the subcommittee determined that the risks of this approach are outweighed by the potential benefit of diagnosing a UTI and treating it appropriately before renal scarring occurs, and, conversely, by avoiding overtreatment and unnecessary and expensive imaging.

• Action Statements 2a and 2b. These also represent "strong recommendations" based on level A evidence, but address those febrile infants who the clinician does not feel require immediate antimicrobial therapy. In these infants, the clinician should assess whether the likelihood of UTI is low or high. Those with a low likelihood of UTI (such as those with another obvious infection, which reduces the likelihood of UTI) can undergo clinical follow-up monitoring without testing; those not in a low-risk group (such as girls and uncircumcised boys, who have a higher risk for UTI) can be managed either by obtaining a urine specimen via catheterization or SPA for culture and urinalysis, or by the most convenient means for urinalysis. If the urinalysis results suggest a UTI, a specimen should then be obtained by catheterization or SPA for culture.

A negative urinalysis, however, suggests it is reasonable to monitor the clinical course without initiating antimicrobial therapy.

• Action Statement 3. This also addresses UTI diagnosis, and states that clinicians should require both urinalysis results that suggest infection (pyuria and/or bacteriuria) and the presence of at least 50,000 colony-forming units per milliliter of a uropathogen cultured from a specimen obtained via catheterization or SPA. Unlike the first two action statements, this one is based on observational studies, and thus is considered level C evidence and represents a "recommendation" rather than a "strong recommendation."

"These criteria reduce the likelihood of overdiagnosis of UTI in infants with asymptomatic bacteriuria or contaminated specimens," the subcommittee wrote.

• 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."

For example, while he agrees that the recommendation on selective urine testing based on the prior probability of UTI is "an important improvement," and he lauded the subcommittee’s job summarizing the factors that determine that probability, he questioned the assertion that the threshold probability for urine testing is below 3%, and proposed that until this is proven, the decision to test should be individualized.

Additionally, while he said he is "glad the new guideline continues to offer the option of obtaining urine for urinalyses noninvasively," he also said he is not convinced that the bag urine can never be used for culture. "If the urinalysis is used to select urine for culture, the prior probability may sometimes be in a range where the bag culture will be useful," he explained.

Despite these and other concerns addressed by Dr. Newman, he saluted the authors and noted that the updated guideline should prove helpful to clinicians and families dealing with this common problem.

Members of the subcommittee that developed this guideline included individuals with expertise in the fields of academic general pediatrics, epidemiology and informatics, pediatric infectious disease, pediatric nephrology, pediatric practice, pediatric radiology, and pediatric urology. The AAP funded the development of the guidelines; none of the subcommittee members had financial conflicts of interest. Dr. Newman also had no financial conflicts to report.

Antimicrobial prophylaxis to prevent febrile recurrent urinary tract infection in infants aged 2 months to 2 years without vesicoureteral reflux or with grade I to IV VUR is not supported by currently available data, and therefore voiding cystourethrography to detect VUR should no longer be used routinely after a first UTI in this population, according to a newly updated American Academy of Pediatrics practice guideline.

The update – the first since 1999 to the guideline regarding the diagnosis and management of the initial UTI in febrile infants and young children – is published in the Aug. 29 issue of Pediatrics (2011;128:595-610 [doi:10.1542/peds.2011-1330]).

The previous guideline included strong encouragement of imaging studies despite insufficient evidence supporting a routine voiding cystourethrogram (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," according to the AAP Subcommittee on Urinary Tract Infection, which authored the updated guideline.

The update, which is intended for use in various clinical settings including offices, hospitals, and emergency departments for the diagnosis and management of the approximately 5% of children in this age group who are affected by UTIs, is based in large part on new data regarding imaging and diagnostic criteria in this population.

It also includes changes as to which children should undergo urine testing, how the sample should be obtained, and how treatment and follow-up should be conducted in those found to have a UTI, according to lead author Dr. Kenneth B. Roberts of Greensboro, N.C., and his subcommittee colleagues.

The "long-awaited update" provides an "exceptionally evidence-based guideline that differs in important ways from the 1999 guidelines and sets a high standard for transparency and scholarship," Dr. Thomas B. Newman of the University of California, San Francisco, wrote in an accompanying editorial (Pediatrics 2011;128:572-75 [doi:10.1542/peds.2011-1818]).

Dr. Newman also said that the guideline and a technical report containing the data on which the recommendations are based represent "a significant advance."

The guideline includes seven recommendations or action statements:

• Action Statement 1. It calls for obtaining a urine specimen for both culture and urinalysis prior to administration of an antimicrobial agent in infants with no apparent source for their fever, and in whom the clinician decides antimicrobial therapy should be administered due to ill appearance or another pressing reason. Since they assert that the diagnosis of UTI cannot be reliably established through culture of urine collected in a bag, the subcommittee says the specimen should be obtained through catheterization or suprapubic aspirate (SPA). The evidence quality for this "strong recommendation" was level A, meaning it is based on well-designed randomized controlled trials or diagnostic studies of relevant populations.

Although catheterization is invasive, the subcommittee determined that the risks of this approach are outweighed by the potential benefit of diagnosing a UTI and treating it appropriately before renal scarring occurs, and, conversely, by avoiding overtreatment and unnecessary and expensive imaging.

• Action Statements 2a and 2b. These also represent "strong recommendations" based on level A evidence, but address those febrile infants who the clinician does not feel require immediate antimicrobial therapy. In these infants, the clinician should assess whether the likelihood of UTI is low or high. Those with a low likelihood of UTI (such as those with another obvious infection, which reduces the likelihood of UTI) can undergo clinical follow-up monitoring without testing; those not in a low-risk group (such as girls and uncircumcised boys, who have a higher risk for UTI) can be managed either by obtaining a urine specimen via catheterization or SPA for culture and urinalysis, or by the most convenient means for urinalysis. If the urinalysis results suggest a UTI, a specimen should then be obtained by catheterization or SPA for culture.

A negative urinalysis, however, suggests it is reasonable to monitor the clinical course without initiating antimicrobial therapy.

• Action Statement 3. This also addresses UTI diagnosis, and states that clinicians should require both urinalysis results that suggest infection (pyuria and/or bacteriuria) and the presence of at least 50,000 colony-forming units per milliliter of a uropathogen cultured from a specimen obtained via catheterization or SPA. Unlike the first two action statements, this one is based on observational studies, and thus is considered level C evidence and represents a "recommendation" rather than a "strong recommendation."

"These criteria reduce the likelihood of overdiagnosis of UTI in infants with asymptomatic bacteriuria or contaminated specimens," the subcommittee wrote.

• 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."

For example, while he agrees that the recommendation on selective urine testing based on the prior probability of UTI is "an important improvement," and he lauded the subcommittee’s job summarizing the factors that determine that probability, he questioned the assertion that the threshold probability for urine testing is below 3%, and proposed that until this is proven, the decision to test should be individualized.

Additionally, while he said he is "glad the new guideline continues to offer the option of obtaining urine for urinalyses noninvasively," he also said he is not convinced that the bag urine can never be used for culture. "If the urinalysis is used to select urine for culture, the prior probability may sometimes be in a range where the bag culture will be useful," he explained.

Despite these and other concerns addressed by Dr. Newman, he saluted the authors and noted that the updated guideline should prove helpful to clinicians and families dealing with this common problem.

Members of the subcommittee that developed this guideline included individuals with expertise in the fields of academic general pediatrics, epidemiology and informatics, pediatric infectious disease, pediatric nephrology, pediatric practice, pediatric radiology, and pediatric urology. The AAP funded the development of the guidelines; none of the subcommittee members had financial conflicts of interest. Dr. Newman also had no financial conflicts to report.