Disposition

Numerous clinical investigators and clinicians have discussed and debated in recent years the most appropriate radiologic studies for the follow-up of children with UTIs, and various algorithms have been proposed.9!0! and !2 Although imaging studies for UTIs are rarely indicated as part of the diagnostic workup in the emergency department (except in cases where there is a palpable mass), it is important to arrange follow-up for all children with febrile UTIs. A recent evidence-based study of the existing literature suggested that large multicenter studies are needed to more carefully delineate a definitive approach to imaging the genitourinary system in children with UTI.11 However, until such studies are completed, the following is a reasonable diagnostic approach to imaging. First, the goals of radiologic imaging are to (1) identify existing upper tract disease capable of causing cortical scaring so that appropriate antibiotic therapy can be instituted, (2) identify treatable lesions of the genitourinary system, and (3) guide an approach to prevent further renal scarring and subsequent impairment of renal function.

In the past, indications for imaging of pediatric patients with UTI included neonates, females with recurrent UTI (two or more episodes), and males of any age with

UTI. However, more recent studies support the approach outlined in Fig 136-1, which some institutions utilize even for patients with a first episode of UTI.12 Acutely febrile and/or toxic children with UTI as the documented or presumed source of fever should have a renal cortical scan (RCS) to assess for renal involvement. If renal scarring and/or active infection is present, the patient should have intravenous antibiotic therapy to reduce scarring and eliminate infection. If the RCS results are negative, males should have a voiding cystourethrogram (VCUG) and females an isotope cystogram (IC) to assess for vesicoureteral reflux. In afebrile children, the VCUG for males and IC for females should initially be assessed, followed by RCS if the results are positive. Renal sonography may be done at the time of RCS, VCUG, or IC to assess for dilatation of the collection system.

FIG. 136-1. Algorithm for radiographic evaluation of children with their first UTI. (Adapted from Gausche M, in Strange GR, ed: Pediatric Emergency Medicine: A Comprehensive Study Guide. New York, McGraw-Hill, with permission.)

While such radiologic imaging is not necessarily coordinated by the emergency department, it is important for emergency physicians to be aware of the necessity of follow-up and the reasons for imaging so that it can be coordinated with the patient's inpatient physician or primary care provider.

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