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## Complete Summary

#### GUIDELINE TITLE

Urinary tract infection---child.

#### BIBLIOGRAPHIC SOURCE(S)

Podberesky DJ, Unsell BJ, Gunderman R, Blatt ER, Coley BD, Fordham L,
Prince JS, Feins N, Rodriguez W, Expert Panel on Pediatric Imaging.
Urinary tract infection - child. \[online publication\]. Reston (VA):
American College of Radiology (ACR); 2006. 7 p. \[70 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Gelfand MJ, Parker BR,
Kushner DC, Babcock DS, Cohen HL, Hernandez RJ, McAlister WH, Royal SA,
Slovis TL, Smith WL, Strain JD, Strife JL, Rushton HG. Urinary tract
infection. American College of Radiology. ACR Appropriateness Criteria.
Radiology 2000 Jun;215(Suppl):847-54.

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Urinary tract infection (UTI)

#### GUIDELINE CATEGORY

Diagnosis

#### CLINICAL SPECIALTY

Family Practice\
Nephrology\
Pediatrics\
Radiology\
Urology

#### INTENDED USERS

Health Plans\
Hospitals\
Managed Care Organizations\
Physicians\
Utilization Management

#### GUIDELINE OBJECTIVE(S)

To evaluate the appropriateness of initial radiologic examinations in
pediatric patients with urinary tract infection

#### TARGET POPULATION

Pediatric patients with urinary tract infection

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Invasive (INV), voiding cystourethrography (VCUG)

2.  Nuclear medicine (NM)

    -   Radionuclide cystography (RNC)

    -   Renal cortical scintigraphy (RCS) plus pinhole imaging or single
        photon emission computed tomography (SPECT)

3.  Ultrasound (US), kidneys and bladder, including power Doppler
    sonography

4.  Computed tomography (CT), abdomen, with contrast

5.  Magnetic resonance imaging (MRI), abdomen and pelvis, with contrast

6.  X-ray, intravenous pyelography (IVP)

#### MAJOR OUTCOMES CONSIDERED

Utility of radiologic examinations in differential diagnosis

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The guideline developer performed literature searches of peer-reviewed
medical journals and the major applicable articles were identified and
collected.

#### NUMBER OF SOURCE DOCUMENTS

The total number of source documents identified as the result of the
literature search is not known.

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Not Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not stated

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

One or two topic leaders within a panel assume the responsibility of
developing an evidence table for each clinical condition, based on
analysis of the current literature. These tables serve as a basis for
developing a narrative specific to each clinical condition.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus (Delphi)

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Since data available from existing scientific studies are usually
insufficient for meta-analysis, broad-based consensus techniques are
needed for reaching agreement in the formulation of the appropriateness
criteria. The American College of Radiology (ACR) Appropriateness
Criteria panels use a modified Delphi technique to arrive at consensus.
Serial surveys are conducted by distributing questionnaires to
consolidate expert opinions within each panel. These questionnaires are
distributed to the participants along with the evidence table and
narrative as developed by the topic leader(s). Questionnaires are
completed by participants in their own professional setting without
influence of the other members. Voting is conducted using a scoring
system from 1-9, indicating the least to the most appropriate imaging
examination or therapeutic procedure. The survey results are collected,
tabulated in anonymous fashion, and redistributed after each round. A
maximum of three rounds is conducted and opinions are unified to the
highest degree possible. Eighty percent agreement is considered a
consensus. This modified Delphi technique enables individual, unbiased
expression, is economical, easy to understand, and relatively simple to
conduct.

If consensus cannot be reached by the Delphi technique, the panel is
convened and group consensus techniques are utilized. The strengths and
weaknesses of each test or procedure are discussed and consensus reached
whenever possible. If \"No consensus\" appears in the rating column,
reasons for this decision are added to the comment sections.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Criteria developed by the Expert Panels are reviewed by the American
College of Radiology (ACR) Committee on Appropriateness Criteria.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**ACR Appropriateness Criteria®**

**Clinical Condition: Urinary Tract Infection \-- Child**

**Variant 1: Age 0-2 years; maximum temperature \<38.5 degrees C.**

  ---------------------------------------------------------------------------
  **Radiologic         **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  INV, VCUG (boys)     9                   Accurate in evaluation of reflux.
                                           Better anatomic differentiation.
                                           Should be cycled.

  NM, radionuclide     9                   Accurate in evaluation of reflux.
  cystography (RNC)                        Lower radiation dose. Use in girls
  (girls)                                  when no anatomic abnormality is
                                           suspected.

  US, kidneys and      9                   Power Doppler sonography should be
  bladder                                  included.

  INV, VCUG (girls)    8                   Useful in girls when significant
                                           anatomic abnormality is suspected
                                           in addition to reflux. Should be
                                           cycled.

  NM, renal cortical   6                   Small infants may present with
  scintigraphy (RCS)                       pyelonephritis without fever.
                                           Consider pinhole and/or SPECT.

  CT, abdomen, with    4                   Also an acceptable method of
  contrast                                 cortical imaging. Higher radiation
                                           dose.

  MRI, abdomen and     4                   Also an acceptable method of
  pelvis, with                             cortical imaging. No ionizing
  contrast                                 radiation. Sedation required.

  NM, radionuclide     2                   Accurate in evaluation of reflux.
  cystography (RNC)                        Lower radiation dose. Poor
  (boys)                                   anatomic differentiation.

  X-ray, intravenous   2                    
  pyelography (IVP)                        

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 2: Age 0-2 years; maximum temperature ≥38.5 degrees C.**

  ---------------------------------------------------------------------------
  **Radiologic         **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  INV, VCUG (boys)     9                   Accurate in evaluation of reflux.
                                           Better anatomic differentiation.
                                           Should be cycled.

  NM, radionuclide     9                   Accurate in evaluation of reflux.
  cystography (RNC)                        Lower radiation dose. Use in girls
  (girls)                                  when no anatomic abnormality is
                                           suspected.

  US, kidneys and      9                   Power Doppler sonography should be
  bladder                                  included.

  INV, VCUG (girls)    8                   Useful in girls when significant
                                           anatomic abnormality is suspected
                                           in addition to reflux. Should be
                                           cycled.

  NM, renal cortical   6                   Small infants may present with
  scintigraphy (RCS)                       pyelonephritis without fever.
                                           Consider pinhole and/or SPECT.

  CT, abdomen, with    5                   Also an acceptable method of
  contrast                                 cortical imaging. Higher radiation
                                           dose.

  MRI, abdomen and     5                   Also an acceptable method of
  pelvis, with                             cortical imaging. No ionizing
  contrast                                 radiation. Sedation required.

  NM, radionuclide     2                   Accurate in evaluation of reflux.
  cystography (RNC)                        Lower radiation dose. Poor
  (boys)                                   anatomic differentiation.

  X-ray, intravenous   2                    
  pyelography (IVP)                        

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 3: Age 2-7 years; maximum temperature \<38.5 degrees C.**

  ---------------------------------------------------------------------------
  **Radiologic         **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  US, kidneys and      9                   Power Doppler sonography should be
  bladder                                  included.

  INV, VCUG (boys)     8                   Accurate in evaluation of reflux.
                                           Better anatomic differentiation.
                                           Consider cycling.

  NM, radionuclide     8                   Accurate in evaluation of reflux.
  cystography (RNC)                        Lower radiation dose. Use in girls
  (girls)                                  when no anatomic abnormality is
                                           suspected.

  INV, VCUG (girls)    7                   Useful in girls when significant
                                           anatomic abnormality is suspected
                                           in addition to reflux. Consider
                                           cycling.

  CT, abdomen, with    4                   Also an acceptable method of
  contrast                                 cortical imaging. Higher radiation
                                           dose.

  MRI, abdomen and     4                   Also an acceptable method of
  pelvis, with                             cortical imaging. No ionizing
  contrast                                 radiation. Sedation required.

  NM, radionuclide     2                   Accurate in evaluation of reflux.
  cystography (RNC)                        Lower radiation dose. Poor
  (boys)                                   anatomic differentiation.

  NM, renal cortical   3                   Consider pinhole and/or SPECT.
  scintigraphy (RCS)                       

  X-ray, intravenous   2                    
  pyelography (IVP)                        

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 4: Age 2-7 years; maximum temperature ≥38.5 degrees C.**

  ---------------------------------------------------------------------------
  **Radiologic         **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  INV, VCUG (boys)     9                   Accurate in evaluation of reflux.
                                           Better anatomic differentiation.
                                           Consider cycling.

  US, kidneys and      9                   Power Doppler sonography should be
  bladder                                  included.

  NM, radionuclide     8                   Accurate in evaluation of reflux.
  cystography (RNC)                        Lower radiation dose. Use in girls
  (girls)                                  when no anatomic abnormality is
                                           suspected.

  INV, VCUG (girls)    7                   Useful in girls when significant
                                           anatomic abnormality is suspected
                                           in addition to reflux. Consider
                                           cycling.

  NM, renal cortical   6                   Consider pinhole and/or SPECT.
  scintigraphy (RCS)                       

  CT, abdomen, with    5                   Also an acceptable method of
  contrast                                 cortical imaging. Higher radiation
                                           dose.

  MRI, abdomen and     5                   Also an acceptable method of
  pelvis, with                             cortical imaging. No ionizing
  contrast                                 radiation. Sedation required.

  NM, radionuclide     2                   Accurate in evaluation of reflux.
  cystography (RNC)                        Lower radiation dose. Poor
  (boys)                                   anatomic differentiation.

  X-ray, intravenous   2                    
  pyelography (IVP)                        

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 5: Age 8+ years; maximum temperature \<38.5 degrees C.**

  ---------------------------------------------------------------------------
  **Radiologic         **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  US, kidneys and      8                   Power Doppler sonography should be
  bladder                                  included.

  INV, VCUG (boys)     5                    

  INV, VCUG (girls)    5                    

  NM, radionuclide     5                    
  cystography (RNC)                        
  (boys)                                   

  NM, radionuclide     5                    
  cystography (RNC)                        
  (girls)                                  

  CT, abdomen, with    4                    
  contrast                                 

  MRI, abdomen and     4                   No ionizing radiation and sedation
  pelvis, with                             likely not required in this age
  contrast                                 group.

  NM, renal cortical   2                   Consider pinhole and/or SPECT.
  scintigraphy (RCS)                       

  X-ray, intravenous   2                    
  pyelography (IVP)                        

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 6: Age 8+ years; maximum temperature ≥38.5 degrees C.**

  ---------------------------------------------------------------------------
  **Radiologic         **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  US, kidneys and      8                   Power Doppler sonography should be
  bladder                                  included.

  INV, VCUG (boys)     5                    

  INV, VCUG (girls)    5                    

  NM, radionuclide     5                    
  cystography (RNC)                        
  (boys)                                   

  NM, radionuclide     5                    
  cystography (RNC)                        
  (girls)                                  

  NM, renal cortical   4                   Most appropriate if localizing
  scintigraphy (RCS)                       symptoms not apparent. Consider
                                           pinhole and/or SPECT.

  CT, abdomen, with    4                    
  contrast                                 

  MRI, abdomen and     4                   No ionizing radiation and sedation
  pelvis, with                             likely not required in this age
  contrast                                 group.

  X-ray, intravenous   2                    
  pyelography (IVP)                        

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Summary of Literature Review**

**Definition of Urinary Tract Infection**

The urinary tract infection (UTI) should be well documented. Specimens
from infants and young children collected in plastic bags are not
acceptable because they are frequently contaminated; the use of bagged
specimens leads to a child undergoing unnecessary imaging procedures.

**Sequelae of Urinary Tract Infection**

Cystitis in the absence of pyelonephritis is not associated with
long-term sequelae. The incidence of scarring in children following
infection of the renal parenchyma varies widely in the literature, with
a mean of about 40% to 45% of cases across a wide age range. Renal
insufficiency is an uncommon sequela of pyelonephritis in childhood,
except in cases where there has been substantial prenatal injury due to
obstruction or vesicoureteral reflux, and in cases with bilateral renal
scarring. Hypertension appears to be a more common sequelum of
moderately severe or severe scarring, affecting 10%--25% of young adults
with significant renal scarring in increasing frequency through their
second, third, and fourth decades. At this time, there is no evidence
that a few scattered small parenchymal scars predispose adolescents or
young adults to hypertension, but there may be some risk of hypertension
associated with medium-sized scars.

**Risk of Pyelonephritis**

Children with vesicoureteral reflux (VUR) are at increased risk for
pyelonephritis and parenchymal scarring. Long-term low-dose antibiotic
suppression is widely used after the acute infection in children with
VUR. Until 1986, it was thought that pyelonephritis in children occurred
only when VUR was present, but it has become clear that more than half
the cases of acute pyelonephritis occur in the absence of VUR. The
incidence of acute pyelonephritis in the absence of documented VUR is
much too high to be explained by intermittent VUR. Pyelonephritis in
these children appears to be due to the same pathogens as in children
with documented VUR. Previous episodes of pyelonephritis and VUR each
place the child at increased risk for future episodes of pyelonephritis.
Accurate diagnosis of acute pyelonephritis may affect the length of stay
in hospitalized patients and may also affect treatment after the acute
infection -- for example, the decision whether to place the child on
antibiotic suppression.

**Imaging Evaluation**

*Clinical Diagnosis of Acute Pyelonephritis*

Approximately 50% to 90% of children hospitalized for acute
pyelonephritis have evidence of acute pyelonephritis by the most
accurate imaging examinations, and clinical signs and laboratory
examinations are only moderately useful. The usual clinical definition
of acute pyelonephritis (particularly in Europe) is fever of greater
than 38.5°C, UTI adequately proven by culture, and elevated acute phase
reactants (usually C-reactive protein \[CRP\] levels \>10 mg/L). In most
series, approximately 50%--80% of children who meet these criteria have
evidence of acute pyelonephritis on cortical scintigraphy.

*Voiding Cystography and VUR*

VUR is detected with equal sensitivity by fluoroscopic contrast voiding
cystourethrography (VCUG) and direct radionuclide cystography (RNC).
Failure to detect reflux by either method is usually due to intermittent
low-grade VUR; in other words, the patient has intermittent VUR but
simply did not reflux at the time the bladder was filled and imaged. A
second filling of the bladder (cyclic cystography) is appropriate in
children under 2 years of age who cannot inhibit voiding, and when there
is a high suspicion that VUR is present, as children in both of these
groups are at higher risk of developing renal damage from urinary
infection. Cyclic cystography may be appropriate in children over 2
years of age as well.

RNC has a much lower absorbed radiation dose than VCUG, but it does not
have the spatial resolution needed to identify anatomic abnormalities of
the urethra, bladder, and ureters. RNC is appropriate for follow-up of
VUR and for screening asymptomatic siblings of children with VUR.
Initial evaluation of VUR in girls may be done by RNC, unless there is
reason to believe that a significant anatomic abnormality of the upper
urinary tract is present (for example, from a prior ultrasound). The
frequency of lower urinary tract findings other than VUR in girls with
UTI is extremely low. Initial evaluation of VUR in boys should not be
done exclusively by RNC, as adequate anatomic imaging of the urethra and
bladder can only be done with VCUG.

**Detection of Acute Pyelonephritis and Renal Parenchymal Scarring**

*Renal Cortical Scintigraphy (RCS)*

RCS using technetium-99m DMSA or technetium-99m glucoheptonate is
sensitive and specific for detecting acute pyelonephritis in animal
studies, with sensitivity of about 90% and specificity of 95%. RCS is
more sensitive than ultrasound (US) and intravenous pyelography (IVP) in
detecting renal parenchymal scars. In the typical clinical setting,
however, acute pyelonephritis and renal parenchymal scarring are usually
but not always distinguishable from each other by RCS. Although RCS
images are of somewhat higher quality when technetium-99m DMSA is used,
technetium-99m glucoheptonate has equal sensitivity for detecting acute
and chronic pyelonephritis and allows identification of most dilated
uropathies (which is somewhat more difficult with DMSA) due to its
approximately 40% to 65% renal excretion. However, in the presence of
significant hydronephrosis or dilative VUR, it may be difficult to
differentiate cortical activity from collecting system activity with
technetium-99m-glucoheptonate, which makes DMSA a more desirable agent
for renal cortical imaging in most cases. Technetium-99m DMSA is
preferred in small infants, in poorly functioning kidneys, and when
other studies have identified dilated uropathy or high-grade VUR.
Pinhole imaging or single photon emission computed tomography (SPECT)
should be considered to maximize the sensitivity of RCS without loss of
specificity. RCS may require sedation in young children.

*Ultrasonography (US)*

Gray-scale ultrasonography identifies about 25% of acute pyelonephritis
and about 40% of chronic parenchymal scarring. Acute pyelonephritic
changes, particularly renal enlargement, cannot be identified on US 1 to
2 weeks after presentation, when the acute infection has cleared. US
reliably identifies severe parenchymal scarring, but not moderate or
minimal scarring. Inter- and intraobserver error makes assessment of
renal growth unreliable after the first year of life unless the period
of observation is at least 12 to 18 months. US cannot reliably identify
VUR, but it is extremely effective in identifying urinary tract
malformations such as hydronephrosis, hydroureter, and ureterocele. It
is noninvasive and does not involve ionizing radiation. While animal
studies have shown power Doppler imaging to be significantly less
accurate in detecting acute pyelonephritis when compared with other
imaging modalities, recent clinical studies in children have shown good
results. A positive power Doppler US may be able to obviate the need for
a renal cortical scan in the detection of acute pyelonephritis in
children.

*Contrast-Enhanced Computed Tomography and Magnetic Resonance Imaging*

Helical contrast-enhanced computed tomography (CT) and magnetic
resonance imaging (MRI) after contrast administration are probably as
sensitive as RCS in detecting acute pyelonephritis. Both CT and MRI
provide more anatomic information about the collecting systems and
ureters than is available from RCS, and both can provide information
about renal scarring. CT has a considerably higher effective absorbed
radiation dose than RCS. MRI is more expensive than CT, typically
requires sedation in young children, and utilizes no ionizing radiation.
MRI may be used to identify ectopic ureters and can provide renal
functional data. Early studies indicate that post-gadolinium imaging may
be most effective in identifying acute pyelonephritis, while T1-weighted
sequences may be all that is necessary for identifying renal scarring.

*Intravenous Pyelography (IVP)*

IVP is insensitive when compared with other imaging modalities in the
diagnosis of acute pyelonephritis or post-infectious scar. It is
valuable in identifying detailed ureteral and calyceal anatomy,
permitting characterization of duplication anomalies when this
information is needed. Routine anatomic diagnosis is usually done by
ultrasonography. IVP examinations in infants are often of poor quality.

**Choice of Upper Urinary Tract Examination in Children**

Acute pyelonephritis may occur in the absence of fever in an infant. If
only a single upper urinary tract examination can be performed, the
physician must compare the relative risk of failing to detect acute
pyelonephritis when only power Doppler US is used to the risk of failing
to detect dilated uropathy when only RCS is used. Appropriate sequencing
of RCS and US also may be used to improve diagnostic yield and control
imaging costs. Whenever it is important to identify both pyelonephritis
and urinary tract dilatation (in an individual or a subpopulation), both
RCS and US should be used, or alternatively, a single contrast-enhanced
CT or MRI examination may be performed.

**Age and the Choice of Examination**

Findings on imaging studies vary considerably according to the age at
which the child is imaged. It is well known that the incidence of VUR
decreases with age. The prevalence of VUR in children with UTI drops
from approximately 50% to 30% from 0 to about 2 years of age, plateaus
at approximately 30% from about 2 to about 7 years of age, and then
drops precipitously at about 7 years of age. Another factor that may
support the use of age-specific algorithms is the higher incidence of
acute pyelonephritis in young children with UTI when compared to infants
with UTI. Infants and toddlers appear to be at greater risk for
extensive renal injury from acute pyelonephritis than older children,
and afebrile pyelonephritis is probably rare after the first year of
life. In the school-age period, children between 5 and 8 years of age
acquire the ability to identify acute pyelonephritis as flank pain. At
the same time, the incidence of acute pyelonephritis is relatively low,
and the incidence of VUR continues to decrease.

**Abbreviations**

-   C, Celsius

-   CT, computed tomography

-   INV, invasive

-   IVP, intravenous pyelography

-   MRI, magnetic resonance imaging

-   NM, nuclear medicine

-   RCS, renal cortical scintigraphy

-   RNC, radionuclide cystography

-   SPECT, single photon emission computed tomography

-   US, ultrasound

-   VCUG, voiding cystourethrography

#### CLINICAL ALGORITHM(S)

Algorithms were not developed from criteria guidelines.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The recommendations are based on analysis of the current literature and
expert panel consensus.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Selection of appropriate radiologic imaging procedures for evaluation of
pediatric patients with urinary tract infection

#### POTENTIAL HARMS

-   Computed tomography (CT), radionuclide cystography (RNC), renal
    cortical scintigraphy (RCS), and voiding cystourethrography (VCUG)
    are associated with radiation.

-   Magnetic resonance imaging (MRI) in small children (under 8 years of
    age) requires sedation.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

An American College of Radiology (ACR) Committee on Appropriateness
Criteria and its expert panels have developed criteria for determining
appropriate imaging examinations for diagnosis and treatment of
specified medical condition(s). These criteria are intended to guide
radiologists, radiation oncologists, and referring physicians in making
decisions regarding radiologic imaging and treatment. Generally, the
complexity and severity of a patient\'s clinical condition should
dictate the selection of appropriate imaging procedures or treatments.
Only those exams generally used for evaluation of the patient\'s
condition are ranked. Other imaging studies necessary to evaluate other
co-existent diseases or other medical consequences of this condition are
not considered in this document. The availability of equipment or
personnel may influence the selection of appropriate imaging procedures
or treatments. Imaging techniques classified as investigational by the
U.S. Food and Drug Administration (FDA) have not been considered in
developing these criteria; however, study of new equipment and
applications should be encouraged. The ultimate decision regarding the
appropriateness of any specific radiologic examination or treatment must
be made by the referring physician and radiologist in light of all the
circumstances presented in an individual examination.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Personal Digital Assistant (PDA) Downloads

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Podberesky DJ, Unsell BJ, Gunderman R, Blatt ER, Coley BD, Fordham L,
Prince JS, Feins N, Rodriguez W, Expert Panel on Pediatric Imaging.
Urinary tract infection - child. \[online publication\]. Reston (VA):
American College of Radiology (ACR); 2006. 7 p. \[70 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1999 (revised 2006)

#### GUIDELINE DEVELOPER(S)

American College of Radiology - Medical Specialty Society

#### SOURCE(S) OF FUNDING

The American College of Radiology (ACR) provided the funding and the
resources for these ACR Appropriateness Criteria®.

#### GUIDELINE COMMITTEE

Committee on Appropriateness Criteria, Expert Panel on Pediatric Imaging

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Panel Members*: Daniel J. Podberesky, MD; Bryan J. Unsell, MD; Richard
Gunderman, MD, PhD; Ellen R. Blatt, MD; Brian D. Coley, MD; Lynn
Fordham, MD; Jeffrey Scott Prince, MD; Neil Feins, MD; William
Rodriguez, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Gelfand MJ, Parker BR,
Kushner DC, Babcock DS, Cohen HL, Hernandez RJ, McAlister WH, Royal SA,
Slovis TL, Smith WL, Strain JD, Strife JL, Rushton HG. Urinary tract
infection. American College of Radiology. ACR Appropriateness Criteria.
Radiology 2000 Jun;215(Suppl):847-54.

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American College of Radiology (ACR) Web
site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonPediatricImaging/UrinaryTractInfectionChildDoc10.aspx).

ACR Appropriateness Criteria® *Anytime*, *Anywhere*™ (PDA application).
Available from the [ACR Web
site](http://www.acr.org/SecondaryMainMenuCategories/ACRStore/FeaturedCategories/QualityandSafety/ac_pda.aspx).

Print copies: Available from the American College of Radiology, 1891
Preston White Drive, Reston, VA 20191. Telephone: (703) 648-8900.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   ACR Appropriateness Criteria®. Background and development. Reston
    (VA): American College of Radiology; 2 p. Electronic copies:
    Available in Portable Document Format (PDF) from the [American
    College of Radiology (ACR) Web
    site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/background_dev.aspx).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI Institute on May 15, 2007.

#### COPYRIGHT STATEMENT

Instructions for downloading, use, and reproduction of the American
College of Radiology (ACR) Appropriateness Criteria® may be found on the
[ACR Web
site.](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/ACRAppropriatenessCriteriaTermsandConditionsDoc1.aspx)

### DISCLAIMER

#### NGC DISCLAIMER

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Date Modified: 11/10/2008