Adherence to urologic imaging guidelines after febrile urinary tract infection in infants.

Abstract

Background: Timely imaging is recommended after febrile UTI (fUTI) in young children to identify treatable urologic conditions. The 2011 American Academy of Pediatrics (AAP) guideline recommends renal bladder ultrasound (RBUS) after fUTI and voiding cystourethrogram (VCUG) after abnormal RBUS or second fUTI.

Objective: We sought to investigate practice pattern variability and associated factors in pediatric fUTI imaging in primary care clinics.

Study design: All children <24 months old with fUTI (temperature ≥38C, positive urinalysis, and >50,000 CFU on urine culture) in a large primary care network in a US Northeast state in 2019 were reviewed. Those with congenital genitourinary anomalies were excluded. We fitted a multivariable logistic regression model with a primary outcome of adherence to the AAP guideline.

Results: In total we included118 patients with fUTI. Overall, post-UTI imaging was adherent to the AAP guideline in 82 cases (69.5 %, See Figure). Reasons for non-adherence were: no RBUS (N = 21), VCUG despite normal RBUS (N = 9), no VCUG after abnormal RBUS (N = 4), and no VCUG after a second fUTI (N = 2). In the multivariable logistic regression model, significant predictors of guideline adherence were commercial insurance (OR = 2.82, p = 0.047), more providers in the practice (OR = 1.38, p = 0.05), and younger provider age (OR = 0.96, p = 0.043) after adjusting for patient's age, sex, maximal temperature during fUTI.

Discussion: Young children with fUTI received guideline-adherent imaging from their primary care clinician approximately 70 % of the time in this sample, though significant opportunities for improvement exist. Guideline adherence was more likely for commercially-insured patients, providers working in larger offices, and younger providers, suggesting both patient and provider characteristics impact the practice pattern.

Conclusion: We observed a wide variation of imaging ordering practice for fUTI in primary care clinic network. Further research may seek to examine reasons for non-adherence, thereby guiding efforts to improve it.