Article Text

PREDICTION OF VESICOURETHERAL REFLUX IN URINARY TRACT INFECTION: TOWARDS A CLINICAL DECISION RULE
  1. S Leroy1,2,
  2. C Romanello3,
  3. A Galetto-Lacour4,
  4. V Smolkin5,
  5. B Korczowski6,
  6. C Rodrigo7,
  7. D Tuerlinckx8,
  8. V Gajdos9,
  9. A Fernandez-Lopez10,
  10. J Friedman11,
  11. N Mourdi2,
  12. I Colombet12,
  13. P Pecile3,
  14. A Gervaix4,
  15. R Halevy5,
  16. B Duhl6,
  17. C Prat7,
  18. T Vander Borght8,
  19. L FoixL’Hélias9,
  20. F Moulin1,
  21. CL Cubells10,
  22. D Gendrel1,
  23. G Bréart2,
  24. M Chalumeau1,2
  1. 1Clinical Epidemiological Unit, Department of Emergency Medicine, Department of Pediatrics, Saint-Vincent-de-Paul Hospital, AP-HP, Université Paris Descartes, Paris, France
  2. 2Departments of Pediatrics, INSERM U149, Paris, France
  3. 3University of Udine, Udine, Italy
  4. 4University Hospital of Geneva, Geneva, Switzerland
  5. 5Ha’Emek Medical Center, Afula, Israel
  6. 6Regional Hospital No 2, University of Rzeszow, Rzeszow, Poland
  7. 7Germans Trias I Pujol Hospital, Badalona, Spain
  8. 8UCL Mont-Godinne, Yvoir, Belgium
  9. 9Antoine Béclère Hospital, Clamart, France
  10. 10Hospital San Joan de Deu, Barcelona, Spain
  11. 11Hospital for Sick Children, Toronto, Canada
  12. 12Department of Hospital Informatics, Georges Pompidou European Hospital, Paris, France

Abstract

During the past decade, many paediatric societies have recommended that all young children undergo a cystography after a first febrile urinary tract infection (UTI). This systematic strategy offered a 100% sensitivity, but without any specificity, meaning that many children underwent an unnecessary cystography, a painful, irradiating and expensive examination. Regarding the recent publications minimising the clinical consequences of low-grade vesicoureteral reflux (VUR), the low rate of high-grade VUR and the current discussions on high-grade VUR treatment, new guidelines propose never to perform a cystography with the risk of recurring UTI and renal scarring. Between both these ends, an evidence-based strategy would find a place to predict high-grade VUR to avoid unnecessary cystography because cystographies miss the least number of patients with high-grade VUR. Procalcitonin has been found and validated to be a strong and sensitive predictor of VUR and especially high-grade VUR in single-centre then multicentre studies (Pediatrics 2005; J Pediatr 2007). The high sensitivity of procalcitonin was then confirmed in children with a DMSA scan-confirmed acute pyelonephritis. However, prediction tools should take into account that clinicians should probably not be ready to make their decision only on a single newly identified biological marker. We recently found performing a systematic review and meta-analysis that ureteral dilation seemed the best renal ultrasound criterion to predict both all-grade and high-grade VUR with a high specificity but a low sensitivity. Therefore, combining such a renal ultrasound criterion with procalcitonin in a clinical decision rule predicting high-grade VUR could be clinically relevant and will be presented.

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