Imaging after a first febrile UTI in infants and children: Less is more?

Although universally recommended by the American Academy of Paediatrics, the need for a voiding cystourethogram (VCUG) following a first febrile urinary tract infection (UTI) in infants continues to generate debate. The UK NICE guidelines recommend a more selective approach for imaging based on defined risk factors. In this study,1 Schroeder and colleagues assessed the impact of incorporating an algorithm adapted from the NICE guidelines into routine clinical care. Study end points included the use of imaging, detection of VUR, antibiotic use and UTI recurrence. Results were provocative. Although adherence to the algorithm was not universal, an 85% reduction in the proportion of children that had a VCUG ordered and a 70% reduction in the number of children prescribed antibiotic prophylaxis was observed post introduction of the algorithm. No increased risk for UTI recurrence was shown within six months. All cases of high-grade VUR (Grade 4–5) were identified but not surprisingly likely cases of low-grade VUR (Grade 1–3), the clinical relevance of which is debatable, were missed. The authors acknowledge several limitations to their study including the criteria used for defining UTI, its retrospective nature, incomplete follow-up data and lack of other imaging modalities including DMSA. Recent trend data within Australia suggest less VCUG scans are being ordered by paediatricians and the study by Schroeder et al. is likely to provide a measure of reassurance in this regard.


Reviewers: William Renton ( and Tom Connell (, Royal Children's Hospital Melbourne.