title: Comparison of procalcitonin and different guidelines for first febrile urinary tract infection in children by imaging.
abstract: BACKGROUND
  We examined the ability of a procalcitonin (PCT) protocol to detect vesicoureteral reflux (VUR) and renal scarring (RS), evaluated procedural costs and radiation burden, and compared four representative guidelines for children with their first febrile urinary tract infection (UTI).
  
  
  METHODS
  Children aged ≤2 years with their first febrile UTI who underwent renal ultrasonography (US), acute and late technetium-99m ((99m)Tc)-dimercaptosuccinic acid scan, and voiding cystourethrography were prospectively studied. The representative guidelines applied in a retrospective simulation included the American Academy of Pediatrics (AAP), National Institute of Clinical Excellence, top-down approach (TDA), and Italian Society of Pediatric Nephrology (ISPN). These were compared in terms of ability to detect abnormalities, procedural costs and radiation.
  
  
  RESULTS
  Of 278 children analyzed, 172 (61.9%) had acute pyelonephritis. There was VUR in 101 (36.3%) children, including 73 (26.3%) with grades III-V VUR. RS was identified in 75 (27.0%) children. To detect VUR, TDA and PCT had the highest sensitivity for grades I-V VUR (80.2%) and III-V VUR (94.5%), respectively, whereas AAP had the highest specificity for I-V VUR (77.4%) and III-V VUR (78.0%), respectively. TDA and PCT had the highest sensitivity (100%) for detecting RS. The highest cost and radiation dose was associated with TDA, whereas AAP had the least expenditure and radiation exposure. By multivariate analysis, PCT and VUR, especially grades III-V, were independent predictors of RS.
  
  
  CONCLUSIONS
  There is no perfect guideline for first febrile UTI children. The PCT protocol has good ability for detecting high-grade VUR and RS. If based on available imaging modalities and reducing cost and radiation burden, clinical suggestions in the AAP guidelines represent a considerable protocol.
authors.affiliation: Department of Pediatrics, Chung Shan Medical University Hospital, No. 110, Section 1, Jianguo North Road, Taichung, 402, Taiwan.
authors.forename: Pei-Fen
authors.initials: PF
authors.lastname: Liao
authors.forename: Min-Sho
authors.initials: MS
authors.lastname: Ku
authors.forename: Jeng-Dau
authors.initials: JD
authors.lastname: Tsai
authors.forename: Yu-Hua
authors.initials: YH
authors.lastname: Choa
authors.forename: Tung-Wei
authors.initials: TW
authors.lastname: Hung
authors.forename: Ko-Huang
authors.initials: KH
authors.lastname: Lue
authors.forename: Ji-Nan
authors.initials: JN
authors.lastname: Sheu
mesh_terms: D000465:Algorithms; D002116:Calcitonin / Q000032:analysis*; D015740:Calcitonin Gene-Related Peptide; D002675:Child, Preschool; D015331:Cohort Studies; D003952:Diagnostic Imaging / Q000191:economics / Q000379:methods*; D005334:Fever; D006801:Humans; D007223:Infant; D007674:Kidney Diseases / Q000175:diagnosis; D017410:Practice Guidelines as Topic; D011498:Protein Precursors / Q000032:analysis*; D011704:Pyelonephritis / Q000175:diagnosis; D019275:Radiopharmaceuticals / Q000191:economics; D019783:Technetium Tc 99m Dimercaptosuccinic Acid / Q000191:economics; D014463:Ultrasonography / Q000191:economics; D014552:Urinary Tract Infections / Q000175:diagnosis*; D014718:Vesico-Ureteral Reflux / Q000175:diagnosis*
chemical_list: C000606589:CALCA protein, human; D011498:Protein Precursors; D019275:Radiopharmaceuticals; D019783:Technetium Tc 99m Dimercaptosuccinic Acid; D002116:Calcitonin; D015740:Calcitonin Gene-Related Peptide