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Editor,—Dr Verrier Jones speaks for all of us in her concluding sentence “The outcome of the systematic review of management of VUR is awaited with interest”.1
However, while we await the outcome, does she infer that invasive imaging is not indicated in the afebrile child with a first simple UTI after 2 years of age?
Similarly is antibiotic prophylaxis not necessary for these children?
Dr Verrier Jones comments:
The investigation of children after recovery from the presenting urinary tract infection (UTI) is a form of screening and should therefore be examined according to the WHO criteria for a worthwhile screening programme.1-1
- The condition sought should be an important health hazard. Recommended imaging tests aim to identify obstruction, vesicoureteric reflux, and renal scarring. All these conditions are potentially serious. Condition fulfilled.
- A latent phase of the condition must be recognised by a simple, acceptable test. While ultrasound can fulfil this requirement, isotope scans are more invasive and less acceptable. Micturating cystography is universally disliked by children1-2 and parents and is only acceptable in special, high risk situations. Condition not fulfilled.
- The natural history must be understood and beneficial effects of treatment must have been established. Some children with renal scarring and a few children without scarring will develop new scars if further UTIs develop, particularly if there is a delay in starting treatment, if the child is very young, and if there is high grade reflux. However, neither long term low dose prophylaxis nor surgery have been shown to influence the development of new scars.1-3 Condition not fulfilled.
- The cost of case finding and treatment must be economically balanced against the expenditure. Stark has expressed doubt about the cost effectiveness of imaging investigations in children following UTIs in childhood.1-4 Condition not fulfilled.
Three of the four criteria for a successful screening programme are not fulfilled for vesicoureteric reflux and renal scarring. The natural history of obstruction is for deteriorating renal function and a risk of severe UTIs. Obstruction can be readily identified by ultrasound. Relief of obstruction is an agreed form of treatment. Thus screening for obstruction using ultrasound may fulfil the criteria for screening.
There is evidence that UTIs in children under 2 years of age are under diagnosed in primary care.1-5 If we believe that scars are acquired and preventable then it would be better to put more effort into detecting UTIs in children under 2 years and ensuring prompt, appropriate treatment.
Prophylaxis has been shown to decrease the risk of recurrent infection in children with normal urinary tracts.1-6 We do not know if prophylaxis is superior to prompt treatment of new infections in the prevention of renal scarring.