1. This prospective cohort study identified several risk factors for recurrent febrile and symptomatic urinary tract infection (UTI) in children, including vesicoureteral reflux (VUR), bowel and bladder dysfunction (BBD), and baseline renal scarring. Children with both VUR and BBD were at highest risk of recurrent febrile or symptomatic UTI.
2. There was no difference in renal scarring rates among children with and without VUR at the end of the 2-year study period.
Evidence Rating Level: 2 (Good)
Study Rundown: UTIs are a common cause of serious bacterial infection in the pediatric population and can result in long-term sequelae, such as recurrent UTIs and renal scarring. This prospective study of children with a history or 1 or 2 febrile/symptomatic UTIs sought to determine risk factors for recurrent UTI and renal scarring, and to compare rates of these complications among children with and without VUR. During the 2-year study period, children with VUR had higher rates of recurrent febrile/symptomatic UTI compared to children without VUR. BBD and presence of renal scarring at baseline were also associated with recurrent UTI. There was no significant difference in renal scarring between children with and without VUR. This study is limited by a small sample size and differences among sites with regard to management of BBD. Nonetheless, this study highlights important risk factors for recurrent UTIs in children to help physicians determine which children may benefit from antimicrobial prophylaxis.
In-Depth [prospective cohort study]: A total of 305 children aged 2 to 71 months with VUR and 195 children without VUR from multiple institutions were observed over a 2-year period. All children had a history of 1 or 2 febrile or symptomatic UTIs prior to enrollment. Parents were contacted every 2 months to ascertain any urinary symptoms or illnesses, and patients were seen in follow-up at 6, 12, 18, and 24 months with DMSA scan to assess for renal scarring and BBD assessment at 1 and 2 years. Children with VUR had a significantly increased rate of recurrent febrile or symptomatic UTI compared to children without VUR (Kaplan-Meier* estimate 25.4% vs. 17.3%). This risk was increased in children with grade III or grade IV VUR, who had a Kaplan-Meier risk estimate of 28.9%. Baseline renal scarring was associated with an increased risk of recurrent febrile or symptomatic UTI (hazard ratio [HR]: 3.21; 95% CI: 1.40-7.33), as was age of 36 to 71 months (HR: 2.49; 95% CI: 1.61-3.85), second UTI at enrollment (HR: 2.08; 95% CI: 1.24-3.50), BBD (HR: 2.01; 95% CI: 1.07-3.76), and white race (HR: 1.70; 95% CI: 1.01-2.86). Children with VUR and BBD had the highest risk of recurrent UTI (Kaplan-Meier estimate 56%) There was no significant difference in renal scarring rates between children with and without VUR.
*The Kaplan-Meier risk estimate is a measure of survival, with higher percentages indicating greater risk of morbidity and mortality due to a certain disease pathology. In this study, it was used to estimate the proportion of children experiencing recurrent febrile or symptomatic UTI in a 2-year period.
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