Call for a Rational Approach for Testing for Urinary Tract Infection as a Source of Fever in Infants

Abstract

In this issue, Annals published a provocative review and interpretation of the literature on the detection and treatment of febrile infants for urinary tract infection. The authors conclude that screening for urinary tract infection in febrile 2to 24month-old children without a source of infection should be undertaken only if there is fever for 4 to 5 days. Their reasoning is that although urinary tract infection may be the most common source of bacterial infection in this age group, it rarely causes sepsis (and therefore there is a low risk of mortality) and that early treatment will not affect long-term morbidity such as end-stage renal failure, hypertension, or lower renal function. This is in direct contradiction to findings from a national panel of experts who reviewed and graded the literature before publishing the latest 2011 American Academy of Pediatrics’ clinical practice guidelines for the diagnosis and management of the initial urinary tract infection in febrile infants and children aged 2 to 24 months. Clinicians evaluating febrile young children must balance the cost and risks of diagnostic tests against the potential benefit of identifying and treating bacterial infection that may be present. This requires an understanding of the magnitude of the estimated benefits and the degree of certainty surrounding them. There are at least 2 rationales for continuing to identify urinary tract infection among young children with fever who are at risk: providing short-term symptomatic relief and preventing progression of disease and possible long-term sequelae. As physicians, we should always question what we think we know. In fact, the management of urinary tract infection in febrile infants is changing because of researchers who have questioned the current standard of care. A recent review discusses the changing management based on new research and thoughtful meta-analyses. There are now 3 relatively recently published guidelines from the United States, Great Britain, and Italy, which put less focus on extensive imaging and prophylactic antibiotics with first-time urinary tract infection and uncomplicated acute pyelonephritis. All 3 guidelines support the rapid treatment of febrile infants with urinary tract infection and strongly emphasize the importance of making an f