Screening of asymptomatic siblings of patients with vesicoureteral reflux

Evidence-based clinical practice guideline for management of urinary tract infection and primary vesicoureteric reflux

We present updated, evidence-based clinical practice guidelines from the Indian Society of Pediatric Nephrology (ISPN) for the management of urinary tract infection (UTI) and primary vesicoureteric reflux (VUR) in children. These guidelines conform to international standards; Institute of Medicine and AGREE checklists were used to ensure transparency, rigor, and thoroughness in the guideline development. In view of the robust methodology, these guidelines are applicable globally for the management of UTI and VUR. Seventeen recommendations and 18 clinical practice points have been formulated. Some of the key recommendations and practice points are as follows. Urine culture with > 104 colony forming units/mL is considered significant for the diagnosis of UTI in an infant if the clinical suspicion is strong. Urine leukocyte esterase and nitrite can be used as an alternative screening test to urine microscopy in a child with suspected UTI. Acute pyelonephritis can be treated with oral antibiotics in a non-toxic infant for 7-10 days. An acute-phase DMSA scan is not recommended in the evaluation of UTI. Micturating cystourethrography (MCU) is indicated in children with recurrent UTI, abnormal kidney ultrasound, and in patients below 2 years of age with non-E. coli UTI. Dimercaptosuccinic acid scan (DMSA scan) is indicated only in children with recurrent UTI and high-grade (3-5) VUR. Antibiotic prophylaxis is not indicated in children with a normal urinary tract after UTI. Prophylaxis is recommended to prevent UTI in children with bladder bowel dysfunction (BBD) and those with high-grade VUR. In children with VUR, prophylaxis should be stopped if the child is toilet trained, free of BBD, and has not had a UTI in the last 1 year. Surgical intervention in high-grade VUR can be considered for parental preference over antibiotic prophylaxis or in children developing recurrent breakthrough febrile UTIs on antibiotic prophylaxis.

Incidence of Urinary Tract Infection Among Siblings of Children With Vesicoureteral Reflux

BACKGROUND

Siblings of children with vesicoureteral reflux (VUR) are at elevated risk of VUR. Screening siblings may identify VUR before a clinical illness such as a urinary tract infection (UTI), but the benefit of screening has not been demonstrated. We sought to determine the incidence of UTI among siblings, and we hypothesized that the sibling UTI rate is similar between screened and unscreened siblings.

METHODS

We performed a retrospective cohort analysis using insurance claims data (January 1, 2000, to December 31, 2009). Within each family, we identified the index VUR patient and siblings; we included siblings who were enrolled in the insurance plan from birth for at least 1 year. We identified siblings who were screened for VUR and/or had UTI. We investigated the association of screening and UTI, controlling for patient characteristics and clustering within families.

RESULTS

Among 617 siblings (associated with 497 index patients), 317 (51%) were girls. Median insurance enrollment time was 53.0 months, with 424 enrolled ≥3 years. Among those with 1 or 3 years of enrollment, the proportions of siblings who experienced UTI was 8.4% (52 of 617) and 10.4% (44 of 424), respectively. Median age at initial UTI was 32.7 months. A total of 223 siblings (36.0%) underwent sibling screening. There was no significant difference in UTI between screened and unscreened siblings (odds ratio 1.57, 95% confidence interval 0.87-2.85; P = .14). In multivariate analysis, screening was not associated with sibling UTI incidence (odds ratio 1.33, 95% confidence interval 0.68-2.60; P = .40).

CONCLUSIONS

Although UTI is relatively common among siblings of VUR patients, there was no statistically significant difference in UTI incidence between screened and unscreened siblings.

Screening siblings for vesicoureteral reflux

PURPOSE

Publications on screening the siblings of patients with reflux were reviewed to determine the overall incidence and severity of reflux and renal scarring in siblings, and identify factors that predict siblings more likely to have reflux.

MATERIALS AND METHODS

A MEDLINE search for 1985 to the present was performed. Of 34 articles on familial reflux only 11, including 1 abstract, on sibling screening were used in this analysis.

RESULTS

The mean incidence of reflux in siblings in all studies was 32% (570 of 1,768). Of the siblings with reflux approximately two-thirds had grades I to II disease. Only 22 of 1,051 siblings (2%) had reflux greater than grade III. Reflux was unilateral in 162 of 307 cases (53%). Certain factors predicted the chance of sibling reflux. Sibling age varied inversely with the incidence of reflux. A twin relationship and absent dysfunctional voiding symptoms in the index patient may predict a higher chance of reflux in a sibling. The mean incidence of renal abnormality in siblings with reflux was 11%. The incidence of reflux and renal abnormality in the sibling population undergoing screening was 3%. In more than half of the siblings with an abnormal renal evaluation there was no history of urinary tract infection.

CONCLUSIONS

The studies reveal an incidence of reflux in siblings greater than in the general population. These data do not prove that screening and treating asymptomatic siblings decreases infectious renal scarring. Studies in a control group that consider sibling age are still needed to determine the benefit of screening asymptomatic siblings.