Shifting science: The New urinary tract infection guidelines
© 2013 Roy Benaroch, MD
Marie wanted to know about urinary tract infections (UTIs) in children. Are they associated with kidney damage? What kind of workup and treatment are now recommended?
This is one of those examples of how changes in our understanding lead to big changes in the way medicine is practiced. It’s part of the power of science—it self-corrects, and through the testing of hypotheses we improve our knowledge of health and medicine. On the other hand, it’s a good example also of how science can frustrate parents and patients. We used to do things one way, then we figured out that the way we were doing it was wrong. Sorry about that. Science lurches on!
In the old days, especially after a 1999 AAP practice parameter, an extensive workup was recommended after even the first UTI in children. The thinking was that at least some UTIs are associated with problems in the urinary tract that could predispose to more UTIs, and even permanent kidney damage that could require dialysis or transplantation. Bad news! The main “predisposing factor” we looked for was vesicoureteral reflux (VUR) which is when urine pushes backwards up the ureters to the kidneys. That “back pressure” was thought to cause kidney scarring.
So, for a decade or so, babies and young children after UTIs underwent kidney ultrasounds and a “VCUG” study involving catheterizing the bladder. Many were diagnosed with VUR and kept on prolonged courses of antibiotics. Some with more serious VUR underwent surgical procedures. Meanwhile, several groups collected data about how these children were doing.
Over the years after that 1999 parameter, several studies showed that the guidance was, well, misguided. Mild-to-moderate VUR usually got better on its own, without causing kidney problems; more-severe VUR could be identified on an ultrasound alone; and prolonged antibiotics didn’t actually prevent infections.
So in 2011 the AAP came out with a new set of guidelines. Gone are the VCUG after the first UTI, and out went the routine use of prophylactic antibiotics. Not everyone agrees with the new guidelines (just like not everyone agreed with the 1999 guidelines), but from what I’ve seen, fewer and fewer pediatricians are ordering those tests.
What certainly hasn’t changed is the need to correctly identify and treat children with UTIs. We do need to look for these infections, especially in young girls with unexplained fevers (or uncircumcised boys less than 6-12 months of age.) When they’re found, they need to be correctly evaluated with a urine specimen and treated with antibiotics; and current thinking suggests that a kidney/bladder ultrasound be done to look for anatomic issues (the ultrasound is painless and doesn’t involve any ionizing radiation, so I have no problem with doing those.)
Science isn’t just a collection of facts or a body of knowledge—it’s a method of figuring things out, and confirming what we suspect. By its nature, science will have false leads and misdirected paths. But in the long run it’s the best way we know of to figure out hw bodies work and how to improve and maintain health. That we blew it on the UTI thing isn’t an indictment of the method, but an illustration of its strength. Give it time, and we’ll make progress. Science*!
* Looks like they pulled the official video of the Thomas Dolby song from Youtube. A tragedy.