Guidelines for treating a first urinary tract infection were not followed in more than half of Medicaid-enrolled infants in Washington State, reported Adam L. Cohen, M.D., and his colleagues at the University of Washington, Seattle.
Although recent studies have questioned the guidelines from the American Academy of Pediatrics, they are “nevertheless generally accepted as recommended care, particularly in high-risk populations in which medical follow-up is uncertain,” Dr. Cohen said (Pediatrics 2005;115:1474–8).
Adhering to the guidelines requires three things: anatomic imaging (urinary tract ultrasonography or renal scan within 3 months of diagnosis), imaging for reflux (voiding cystourethrography or renal scan within 3 months of diagnosis), and antimicrobial prophylaxis (antibiotic therapy after diagnosis until imaging for reflux is performed).
In a retrospective cohort study of Washington's Medicaid data, 780 patients (2.1% of eligible patients in their first year of life) were diagnosed with a first urinary tract infection, and 302 (38.7%) were hospitalized.
Of those who were diagnosed with a urinary tract infection, 28.2% of patients received both anatomic imaging and imaging for reflux, 15.8% received only anatomic imaging, and 11.3% received only imaging for reflux. Of those who received imaging for reflux, more than half (51%) had adequate antibiotics between diagnosis and imaging.
Hospitalization was associated with better adherence to imaging recommendations, perhaps because these patients were more acutely ill or because hospitals may have policies in place to ensure guideline compliance, the investigators said. In a controlled, multivariate analysis, hospitalized patients were significantly more likely than were outpatients to get anatomic imaging (relative risk 1.38) and imaging for reflux (relative risk 1.62).
And patients 90 days or younger were less likely to receive antimicrobial prophylaxis than were older patients (relative risk 0.59).