URINARY-TRACT INFECTIONS IN GIRLS - THE COST-EFFECTIVENESS OF CURRENTLY RECOMMENDED INVESTIGATIVE ROUTINES

Current recommendations for the universal investigation of urinary tra ct infection (UTI) in children by ultrasonography, voiding cystourethr ography, mercaptosuccinic acid renal scan (and sometimes intravenous p yelography as well) are not based on any convincing evidence as to the necessity or effectiveness of such a routine. Over 8% of all girls wi ll have a UTI during childhood. About 87 individuals in a million will develop end-stage renal disease (ESRD) by the age of 60 years, caused in about 9% by pyelonephritis (PN) or reflux nephropathy. From these statistics, the maximal risk of a first diagnosed UTI progressing to E SRD is approximately 1:10,000. The risk of developing hypertension fol lowing a first UTI in childhood, without eventual evolution to ESRD, a ppears to be very small. The cost of the widely recommended routine im aging procedures ranges from U.S. $ 355 in Britain to U.S. $ 1,090 in the United States. The minimal cost of preventing a single progression to ESRD by early diagnosis of underlying pathology - if this were pos sible in all cases - would range between U.S. $ 5 million in Britain a nd U.S. $ 15 million in the United States. Since in many instances pro gressive renal damage can not be prevented, the true cost is considera bly higher. Lower UTI in girls is a very common and, in most cases, be nign finding in primary-care practice. It is suggested that girls with afebrile UTI, presenting with lower urinary tract symptoms alone, nee d not undergo any imaging procedures, but should be followed with urin e examinations and cultures at the time of febrile illness. The recomm ended investigative routines should be reserved for UTI in infants and in girls with fever or other symptoms suggesting PN, and for proven r ecurrent Un. Such a regimen will allow a marked saving in terms of cos ts and in terms of unneccessary radiation, psychological stress to chi ldren, and stress, inconvenience, and time loss to parents. There is n o evidence that this approach will compromise the course or final outc ome of this very common condition.