title: Prediction of moderate and high grade vesicoureteral reflux after a first febrile urinary tract infection in children: construction and internal validation of a clinical decision rule.
abstract: OBJECTIVE
  Urinary tract infection leads to a diagnosis of moderate or high grade (III or higher) vesicoureteral reflux in approximately 15% of children. Predicting reflux grade III or higher would make it possible to restrict cystography to high risk cases. We aimed to derive a clinical decision rule to predict vesicoureteral reflux grade III or higher in children with a first febrile urinary tract infection.
  
  
  METHODS
  We conducted a secondary analysis of prospective series including all children with a first febrile urinary tract infection from the 8 European participating university hospitals.
  
  
  RESULTS
  A total of 494 patients (197 boys, reflux grade III or higher in 11%) were included. Procalcitonin and ureteral dilatation on ultrasound were significantly associated with reflux grade III or higher and then combined into a prediction model with an ROC AUC of 0.75 (95% CI 0.69-0.81). Given the prespecified constraint of achieving at least 85% sensitivity, our model led to the clinical decision rule, for children with a first febrile urinary tract infection cystography should be performed in cases with ureteral dilatation and serum procalcitonin level 0.17 ng/ml or higher, or without ureteral dilatation (ie ureter not visible) when serum procalcitonin level is 0.63 ng/ml or higher. The rule had 86% sensitivity (95% CI 74-93) with 47% specificity (95% CI 42-51). Internal cross-validation produced 86% sensitivity (95% CI 79-93) and 43% specificity (95% CI 39-47).
  
  
  CONCLUSIONS
  A clinical decision rule was derived to enable a selective approach to cystography in children with urinary tract infection. The rule predicts high grade vesicoureteral reflux with approximately 85% sensitivity and avoids half of the cystograms that do not find reflux grade III or higher. Further validation is needed before its widespread use.
authors.affiliation: Center for Statistics in Medicine, University of Oxford, Oxford, United Kingdom. sandrine.leroy@pasteur.fr
authors.forename: Sandrine
authors.initials: S
authors.lastname: Leroy
authors.forename: Carla
authors.initials: C
authors.lastname: Romanello
authors.forename: Vladislav
authors.initials: V
authors.lastname: Smolkin
authors.forename: Annick
authors.initials: A
authors.lastname: Galetto-Lacour
authors.forename: Bartosz
authors.initials: B
authors.lastname: Korczowski
authors.forename: David
authors.initials: D
authors.lastname: Tuerlinckx
authors.forename: Carlos
authors.initials: C
authors.lastname: Rodrigo
authors.forename: Vincent
authors.initials: V
authors.lastname: Gajdos
authors.forename: Florence
authors.initials: F
authors.lastname: Moulin
authors.forename: Paolo
authors.initials: P
authors.lastname: Pecile
authors.forename: Raphaël
authors.initials: R
authors.lastname: Halevy
authors.forename: Alain
authors.initials: A
authors.lastname: Gervaix
authors.forename: Barbara
authors.initials: B
authors.lastname: Duhl
authors.forename: Thierry
authors.initials: T
authors.lastname: Vander Borght
authors.forename: Cristina
authors.initials: C
authors.lastname: Prat
authors.forename: Laurence
authors.initials: L
authors.lastname: Foix-L'Hélias
authors.forename: Douglas G
authors.initials: DG
authors.lastname: Altman
authors.forename: Dominique
authors.initials: D
authors.lastname: Gendrel
authors.forename: Gérard
authors.initials: G
authors.lastname: Bréart
authors.forename: Martin
authors.initials: M
authors.lastname: Chalumeau
mesh_terms: D003661:Decision Support Techniques; D005260:Female; D005334:Fever / Q000150:complications*; D005544:Forecasting; D006801:Humans; D007223:Infant; D008297:Male; D011446:Prospective Studies; D012720:Severity of Illness Index; D014552:Urinary Tract Infections / Q000150:complications*; D014718:Vesico-Ureteral Reflux / Q000453:epidemiology / Q000209:etiology*