“ First urinary tract infection episode in children:

Are procalcitonin values

& ultrasound examination of importance

in the diagnosis of upper urinary tract infection ? ”

S.P. Deftereos, A. Kotoula, E. Vranou, A. Zisimopoulos, A. Chadjimichail, P. Prassopoulos

Democritus University of Thrace, Department of Radiology, Alexandroupolis, Greece

URINARY TRACT INFECTIONS

Differential diagnosis

between upper and

lower urinary tract

infection

Acute pyelonefritis

Scars Hypertension

C.R.D

GENERAL APPROACH until today…

Clinical evaluation

Temperature ≥38oC, presence of vomiting or

diarrhea, decreased oral intake

Laboratory investigation

ESR, CRP, leukocyte count, positive culture

of urine speciment

116-amino-acid propeptide

of calcitonin

New marker of bacterial

infections

Under physiological

conditions undetectable

Very high levels in

response to bacterial

infections

Decreases within 48h of the

administration of antibiotics

PROCALCITONIN (PCT)

DMSA

Gold standard method but

Costs

Limit availability

Inability to differentiate old scarring

from acute

Exposure of patients to radiation

ULTRASOUND

Noninvasive with no risk to

the patient

Easily performed method

No exposure to radiation but

Strongly dependent on the operator

Children are not always cooperative

VCUG

Information for VUR but

Performed after UTI treatment

Radiation exposure (gonads)

Invasive method

DMSA

ULTRASOUND

PCT

WBC

ESR

CRP

UUTI

AIM

To examine the efficacy of ultrasonography

(US) findings in combination with

procalcitonin (PCT) values in predicting renal

parenchymal involvement (RPI) in children

with urinary tract infection (UTI)

PATIENTS AND METHODS

Prospective study

57 children (mean age: 12months, range: 2 -

108months)

First episode of UTI

Children with a history of prior UTI were not included

N=43 N=14

Clinical evaluation:

Temperature ≥38oC, vomiting / diarrhea, decrease oral intake

Laboratory investigation includes:

Urine specimens culture

Leukocyte count

Erythrocyte sedimentation rate (ESR)

C-reactive protein (CRP) and

serum PCT

PATIENTS AND METHODS

Imaging evaluation includes:

US: within 48hDMSA: within 7 days and VCUG: after 4-5 weeks (n:51/57pts)

A follow up DMSA was performed after 6 months to examine possible persistent renal lesions

PATIENTS AND METHODS

RESULTS

Upper UTI (group A, n: 27 children)

DMSA positive, abnormal US (n=15, 55.6%)

Lower UTI (group B, n: 30 children)

DMSA negative, US no abnormalities

(except 4 pts with urinary bladder thickening)

N=8

N=21

N=18

N=12

N=27 N=30

PCT

+

+

DMSA + US +

Follow Up

RESULTS

RESULTS

Hyperechoic renal parenchyma

Collecting system dilatation

Increased total kidney volume

Scars (congenital, others)

CDS- irregular vascularity

ULTRASOUND FINDINGS

All infection markers, except LC, have the same diagnostic value

PROGNOSTIC VALUE ?

Group A (N=27) median (range) Group B (N=30) median (range) P value

Leukocyte count (/μl) 19,000 (8,000-27,000) 12,750 (4,500-23,500) 0.056

ESR (mm/h) 40 (27-98) 17.5 (2-75) <0.001

CRP (mg/dl) 9 (1.9-35) 0.5 (0.1-6.5) <0.001

PCT (ng/ml) 4.8 (0.5-13.2) 0.3 (0.1-0.9) <0.001

RESULTS

PCT levels were significantly higher in patients with

persistent renal lesions or/and VUR (n=8) * than in those

with total regression of RPI (n=15) (p=0,004)

*Vesicoureteral reflux (VUR) was

disclosed by VCUGin 14/51(27,4%, 8

group A, 6 group B) cases

PCT cut off:

>0.5ng/ml NPV

>0.85ng/ml NPPV

>1.2ng/ml PPV

RESULTS

DMSA is required in patients

with high PCT levels and

negative US examined

CONCLUSIONS

The combination of high PCT

levels and positive US findings

is an indication of upper UTI

CONCLUSIONS

Normal US and PCT levels

can exclude upper UTI

…and thus protect small patient from unnecessary DMSA