title: Different guidelines for imaging after first UTI in febrile infants: yield, cost, and radiation.
abstract: OBJECTIVE
  To evaluate the yield, economic, and radiation costs of 5 diagnostic algorithms compared with a protocol where all tests are performed (ultrasonography scan, cystography, and late technetium(99)dimercaptosuccinic acid scan) in children after the first febrile urinary tract infections.
  
  
  METHODS
  A total of 304 children, 2 to 36 months of age, who completed the diagnostic follow-up (ultrasonography, cystourethrography, and acute and late technetium(99)dimercaptosuccinic acid scans) of a randomized controlled trial (Italian Renal Infection Study 1) were eligible. The guidelines applied to this cohort in a retrospective simulation were: Melbourne Royal Children's Hospital, National Institute of Clinical Excellence (NICE), top down approach, American Academy of Pediatrics (AAP), and Italian Society of Pediatric Nephrology. Primary outcomes were the yield of abnormal tests for each diagnostic protocol; secondary outcomes were the economic and radiation costs.
  
  
  RESULTS
  Vesicoureteral reflux (VUR) was identified in 66 (22%) children and a parenchymal scarring was identified in 45 (15%). For detection of VUR (47/66) and scarring (45/45), the top down approach showed the highest sensitivity (76% and 100%, respectively) but also the highest economic and radiation costs (€52 268. 624 mSv). NICE (19/66) and AAP (18/66) had the highest specificities for VUR (90%) and the Italian Society of Pediatric Nephrology had the highest specificity (20/45) for scars (86%). NICE would have been the least costly (€26 838) and AAP would have resulted in the least radiation exposure (42 mSv).
  
  
  CONCLUSIONS
  There is no ideal diagnostic protocol following a first febrile urinary tract infection. An aggressive protocol has a high sensitivity for detecting VUR and scarring but carries high financial and radiation costs with questionable benefit.
authors: Nephrology, Dialysis Unit, Department of Pediatrics, Azienda Ospedaliero Universitaria Sant'Orsola-Malpighi Bologna, Bologna, Italy.
authors: Claudio
authors: C
authors: La Scola
authors: Chiara
authors: C
authors: De Mutiis
authors: Ian K
authors: IK
authors: Hewitt
authors: Giuseppe
authors: G
authors: Puccio
authors: Antonella
authors: A
authors: Toffolo
authors: Pietro
authors: P
authors: Zucchetta
authors: Francesca
authors: F
authors: Mencarelli
authors: Martino
authors: M
authors: Marsciani
authors: Roberto
authors: R
authors: Dall'Amico
authors: Giovanni
authors: G
authors: Montini
mesh_terms: D002675:Child, Preschool; D003362:Cost-Benefit Analysis; D005260:Female; D005334:Fever / Q000175:diagnosis* / Q000191:economics* / Q000453:epidemiology; D005500:Follow-Up Studies; D006801:Humans; D007223:Infant; D008297:Male; D017410:Practice Guidelines as Topic / Q000592:standards*; D011446:Prospective Studies; D011829:Radiation Dosage; D014552:Urinary Tract Infections / Q000175:diagnosis* / Q000191:economics / Q000453:epidemiology