Szlyk Gregory R, Williams Stephen B, Majd Massoud, Belman A Barry, Rushton H Gil
Department of Pediatriic Urology, Children's National Medical Center andd the George Washington Univeristy Medical Center, Washington, DC 20010, USA.
J Urol. 2003 Oct;170(4 Pt 2):1566-8; discussion 1568-9. doi: 10.1097/01.ju.0000085962.68246.ce.
Breakthrough urinary tract infections (UTI) are considered an indication for surgical intervention in children with vesicoureteral reflux (VUR) with the goal of preventing new or progressive renal scarring. We assessed the incidence of new renal parenchymal inflammatory changes following breakthrough UTI in patients on antibiotic prophylaxis for VUR.
We prospectively analyzed 38 patients (62 refluxing renal units) with VUR. All patients experienced a culture documented breakthrough UTI (greater than 100,000 cfu/ml) while taking antibiotic prophylaxis. Dimercapto-succinic acid (DMSA) scans were obtained 4 to 6 weeks after UTI to detect new renal inflammatory changes and all scans were reviewed by the same pediatric nuclear medicine specialist (MM). To avoid misinterpretation of preexistent renal scarring for acute inflammation, new pyelonephritis was confirmed by comparison to prior DMSA scan.
Of 38 patients 14 (38%) had preexistent renal scarring but only 1 (7%) manifested new changes on DMSA scan. Of the remaining 24 patients with normal baseline studies 3 (12.5%) had changes after UTI. Overall, only 4 patients (10.5%) manifested new changes on DMSA scan. Three additional patients who did not have a baseline scan for comparison demonstrated unequivocal changes of acute pyelonephritis on DMSA scan, increasing the incidence to 17% (7 of 41). Of the patients 7 (17%) underwent surgical correction of reflux and 34 (83%) were maintained on antibiotic prophylaxis.
Of patients with VUR who experienced a single breakthrough UTI while on antibiotic prophylaxis, at most only 17% had renal inflammatory changes on acute DMSA scan. Our findings endorse the usefulness of DMSA scan in tailoring management of VUR and breakthrough UTI cases, and lend support to continued nonoperative management for the majority.
突破性尿路感染（UTI）被视为对患有膀胱输尿管反流（VUR）的儿童进行手术干预的指征，目的是预防新的或进行性肾瘢痕形成。我们评估了接受VUR抗生素预防的患者在发生突破性UTI后新的肾实质炎症变化的发生率。
我们前瞻性分析了38例患有VUR的患者（62个反流肾单位）。所有患者在接受抗生素预防期间均经历了一次经培养证实的突破性UTI（大于100,000 cfu/ml）。在UTI发生后4至6周进行二巯基丁二酸（DMSA）扫描以检测新的肾脏炎症变化，所有扫描均由同一位儿科核医学专家（MM）进行复查。为避免将先前存在的肾瘢痕误判为急性炎症，通过与先前的DMSA扫描进行比较来确诊新的肾盂肾炎。
38例患者中，14例（38%）先前存在肾瘢痕，但只有1例（7%）在DMSA扫描上出现新变化。其余24例基线检查正常的患者中，3例（12.5%）在UTI后出现变化。总体而言，只有4例患者（10.5%）在DMSA扫描上出现新变化。另外3例未进行基线扫描以供比较的患者在DMSA扫描上显示出明确的急性肾盂肾炎变化，使发生率增至17%（41例中的7例）。这些患者中，7例（17%）接受了反流手术矫正，34例（83%）继续接受抗生素预防。
在接受抗生素预防期间发生单次突破性UTI的VUR患者中，急性DMSA扫描显示最多只有17%的患者有肾脏炎症变化。我们的研究结果支持DMSA扫描在制定VUR和突破性UTI病例管理方案中的有用性，并为大多数患者继续采用非手术管理提供了支持。
