Does prompt treatment of urinary tract infection in preschool children prevent renal scarring: mixed retrospective and prospective audits

Abstract

Objective: To test whether active management of urinary tract infections (UTI) in young children by general practitioners can reduce kidney scarring rates.

Design: A comparison of two audits in Newcastle, of children aged <8 years, presenting with UTIs ; a retrospective audit of conventional management during 1992-1995 (1990s) versus a prospective audit of direct access management during 2004-2011 (2000s).

Main outcome measures: Kidney scarring rates, and their relationship with time-to-treat.

Results: Children with a first UTI in the 2000s compared to those in the 1990s, were referred younger, were half as likely to have a renal scar (girls OR 0.47, 95% CI 0.29 to 0.76; boys 0.35, 0.16 to 0.81), and were about 12 times more likely to have vesicoureteric reflux without scarring (girls 11.9, 4.3 to 33.5; boys 14.4, 4.3 to 47.6). In the 2000s, general practitioners treated about half the children at first consultation. Children who were treated within 3 days of their symptoms starting were one-third as likely to scar as those whose symptoms lasted longer (0.33, 0.12 to 0.72).

Interpretation: Most kidney defects seen in children after UTIs, are acquired scars, and in Newcastle, active management in primary care has halved this rate.

Keywords: prompt treatment; renal scarring; urinary tract infection; vesicoureteric reflux.

Figure 1

Cumulative referral rates of girls and boys with a urinary tract infection (UTI) in Newcastle, using a conventional UTI management model up to the age of 16 years during 1990s (open circles), and using the direct access model up to the age of 8 years during the 2000s (filled circles).

Figure 2

Flow chart showing the imaging and management outcomes (both shaded in grey) of 2069 children born after 1 January 2004, that were referred to the direct access service in Newcastle with a possible urinary tract infection, through 2011. *Defined as a pure growth of ≥10⁵/mL of E coli, Proteus, Klebsiella, Pseudomonas or Enterococcus species. **Five children have not been tested for vesicoureteric reflux(VUR) yet; being treated clinically as if they have VUR, and will have a delayed MAG3.

Figure 3

Percentage rates for focal scarring (black bars) and isolated vesicoureteric reflux (grey bars) among girls and boys in Newcastle after a urinary tract infection. The left-hand charts are for conventional management during the 1990s, and the right-hand charts are for direct access during the 2000s.

Figure 4

Number of days of intervals for parents to take their child with a urinary tract infection to their GP after the onset of their first symptoms, the interval for the GPs to then prescribe antibiotics, and the total days between the child developing symptoms and being prescribed antibiotics. The left-hand charts refer to children with normal renal tract imaging. On the right, the grey bars are for children with isolated vesicoureteric reflux, and the black ones are children with focal scars.