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• Ineffective intervention and pointless investigation after childhood urinary tract infection
  Rollo D Clifford
  Published on: 3 September 2003

• Published on: 3 September 2003

  Ineffective intervention and pointless investigation after childhood urinary tract infection

  • Rollo D Clifford, Consultant Paediatrician

  Dear Editor

  Wheeler and colleagues are to be applauded for putting another nail in the coffin of the routine MCUG, a distressing and potentially harmful intervention which has been imposed on thousands of unhappy children, with the best of intentions, but, unfortunately, based upon assumption, anecdote and extrapolation.

  Unless something has been left out of the reporting of the International Reflux Study (I...

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  Dear Editor

  Wheeler and colleagues are to be applauded for putting another nail in the coffin of the routine MCUG, a distressing and potentially harmful intervention which has been imposed on thousands of unhappy children, with the best of intentions, but, unfortunately, based upon assumption, anecdote and extrapolation.

  Unless something has been left out of the reporting of the International Reflux Study (IRS), Wheeler et al. are incorrect in stating that "a randomised comparison between surgical treatment and antibiotic treatment has not been performed". Surely the IRS was in fact just such a study showing no useful benefit of one intervention over the other both in terms of frequency of UTI or scarring.[1] It could well be argued that the absence of benefit for the addition of surgery to antibiotic prophylaxis shown in the Birmingham Reflux Study (BRS) over and above antibiotic treatment is likely to indicate that surgery is ineffective.[2] If that is the case, then the absence of a difference in the IRS between surgery alone and antibiotics alone may well indicate, not so much that both are equally effective as that both are equally ineffective!

  It is noteworthy that 14 years ago Professor White, co-author of the BRS, suggested that a controlled trial of antibiotic prophylaxis would now be ethical.[3] Nevertheless, antibiotic prophylaxis with trimethoprim is a relatively innocuous intervention and, pending such a good controlled trial, it would, perhaps, be a brave paediatrician who would deny this during infancy and maybe up to 2 years. Surprisingly, this is exactly the practice of many following a normal MCUG, notwithstanding the continuation of UTI following surgery and the complete absence of reflux in 30% of infants with abnormal DMSA scans following UTI.[4]

  Anecdotally this DGH unit is not unusual in having abandoned the MCUG as an investigation performed with the sole indication of UTI - despite consensus recommendations! The practice in this unit following infantile UTI remains to provide prophylaxis to all infants up to two years. Investigation, however, in the presence of normal renal ultrasound examination (US) and urinary stream is limited to annual BP, urine testing for protein and US to monitor renal growth until a single DMSA scan can be performed at 4 years.[5] Outside this age group DMSA is only performed in the presence of symptomatic pyelonephritis or abnormal ultrasound.[6]

  References

  (1) Jodal U et al. Infection pattern in children with vesicoureteral reflux randomly allocated to operation or long-term antibacterial prophylaxis. The International Reflux Study in Children. J Urol 1992;148:1650-1652.

  (2) Birmingham Reflux Study Group. Prospective trial of operative versus non -operative treatment of severe vesico-ureteric reflux in children: five years observation. BMJ 1987;295:237-241.

  (3) White RHR. Vesicoureteric reflux and renal scarring. Arch Dis Child 1989;64:407-412.

  (4) Gleeson FV, Gordon I. Imaging in urinary tract infection. Arch Dis Child 1991;66:1283.

  (5) Vernon SJ et al. New renal scarring in children who at age 3 and 4 years had normal scans with dimercaptosuccinic acid: follow up study. Br Med J 1997;315:905-9.

  (6) Rickwood A et al. Current imaging of childhood urinary infections: prospective survey. Br Med J 1992;304:663-5.

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  Conflict of Interest:
  None declared.

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