- Under 6/12, USS for all, within 6 weeks. Urgent if recurrent or atypical features (other than funny bugs).
- Provided things settle within 48 hours of treatment, no further investigations are required unless atypical or recurrent, in which case everyone gets DMSA (6 months after infection) and MCUG.
- 6/12 to 3yrs: USS only if doesn’t settle within 48 hours of treatment. If atypical or recurrent then USS and DMSA (USS urgent if atypical features, other than funny bugs), else within 6 weeks.
- Consider MCUG if dilatation on US, or family history of VUR, or atypical bugs, or poor flow. (MAG3 if continent)
- Over 3yrs: same, except no DMSA even if atypical features, and no mention of MCUG at all.
If USS abnormal, refer for consideration of further imaging.
- USS – not much evidence for benefit, esp if normal antenatal scan, rarely changes management even if something minor found, but harmless. If dilatation seen, do MCUG urgently.
- MCUG – like GORD, maybe you see reflux, maybe you don’t, so can you rely on it? NB Cost, radiation, discomfort…
- DMSA – acutely, diagnoses pyelonephritis. Then remain positive for up to 6 months after an infection. Late scan diagnoses scars. But if negative during first UTI episode, rarely (NPV 88%) have VUR and never high-grade VUR. [J Pediatrics Volume 150, 1 , January 2007, 96-99]
- Antibiotic prophylaxis – not routinely. If considered on the basis of risk/benefit discussion, then use trimethoprim. If trimethoprim resistance, consider strategy of early empirical treatment rather than use a broad spectrum antibiotic such as co-amoxiclav or cefalexin (else risk of highly resistant bugs). [Hoberman A, NEJM 2003] Review every 3-6 months.
- Cycling of antibiotic for prophylaxis may be more rational eg every 2-4 weeks
Studies do not address whether placebo or nothing is worse than prophylaxis (Cochrane: suggests about 36% reduction in infection, but all 3 studies biased, and most other work has prophylaxis vs surgery). Eg Sweden, only screen if additional risk factor, and v low prevalence of scars. Garin study (Paeds 2006) non placebo controlled, found no protection from recurrent infection with antibiotic prophylaxis (the rate for those with reflux was close to significance but seemed to be cystitis rather than pyelo) – plus the bugs were resistant. The rate of scarring was actually higher in the prophylaxis group…
[(Roberts, Kenneth) PIDJ 23(12); 2004:1163-1164 ]