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Abstract

We thank Kaneko et al for their comments. Because of the non-invasive nature of ultrasound scanning and the possibility of identifying a potential underlying cause of infection, we believe that renal ultrasound scanning should continue to be part of the routine care of infants with a first episode of febrile urinary tract infection. It seems illogical to recommend routine cystourethrography, an invasive test with a high burden of radiation, even in small babies with a proven urinary tract infection. The recommendation to focus imaging investigations on cystourethrography, when vesicoureteral reflux is seen in 21% of children, whereas high-grade cases are seen in only 7% of children, is difficult to follow. This attitude continues to generate a massive workload for radiology departments and exposes large numbers of infants to aggressive treatmen without much evidence of benefit. We now have enough data to show that the recurrence rate of infection in patients with low-grade reflux is similar to that observed in patients without vesicoureteral reflux.1Garin E.H. Olavarria F. Garcia Nieto V. Valenciano B. Campos A. et al.Clinical significance of primary vesicoureteral reflux and urinary antibiotic prophylaxis after acute pyelonephritis: a multicenter, randomized, controlled study.Pediatrics. 2006; 117: 626-632Crossref PubMed Scopus (462) Google Scholar, 2Montini G. Rigon L. Zucchetta P. Fregonese F. Toffolo A. Gobber D. et al.IRIS Group. Prophylaxis after first febrile urinary tract infection in children? A multicenter, randomized, controlled, noninferiority trial.Pediatrics. 2008; 122: 1064-1071Crossref PubMed Scopus (255) Google Scholar All infants in our study with high-grade reflux had hydronephrosis, signs of dysplasia visualized on ultrasound scanning, or both and would have had more intensive investigation. Our purpose was not to declare a crusade against cystourethrography. However, one should remember that the guiding principle must be to undertake appropriate investigations with the lowest radiation and least invasive techniques. For that purpose, high-quality ultrasound scanning is the first examination that makes sense, the results of which determine the need for further investigations. We agree, however, with Kaneko et al that an important caveat to this recommendation is the reminder that the imaging must be performed with strictly standardized imaging techniques. We agree that a larger series of infants would be needed to make this a definitive recommendation for others to follow. Vesicoureteric reflux in infants with febrile urinary tract infection: Avoiding a cystourethrogram cannot be justified yetThe Journal of PediatricsVol. 159Issue 2PreviewWe read with interest the report by Ismaili et al.1 They concluded that when renal ultrasound scanning examination (US) results were normal in young infants after a urinary tract infection (UTI), the risk of missing high-grade vesicoureteric reflux (VUR) was extremely low. This statement is based on the findings that the sensitivity rate of abnormal findings of the urinary tract on US for detecting the presence of high-grade (grade IV-V) VUR was 100%, and the negative predictive value was 100%. All 3 infants with high-grade VUR detected with a voiding cystourethrogram (VCUG) had abnormal US findings, and 29 infants with low-grade (grade I- III) VUR or normal urinary tract showed a no abnormal US results. Full-Text PDF