Introduction

Controversy exists regarding the 2011 AAP guidelines for voiding cystourethrogram (VCUG) ordering in the setting of febrile urinary tract infection (UTI) in children aged 2-24 months. We aimed to (1) determine rates of provider compliance by specialty and (2) evaluate the association between guideline adherence and VCUG result.

Methods

We completed a retrospective review of all patients undergoing VCUG at our institution from 1/12-12/13. Patients with neurogenic bladder, known genitourinary abnormality, known vesicoureteral reflux, or those >18 years of age were excluded. The primary outcome was adherence to the 2011 guidelines for VCUG acquisition. Relationships between provider specialty (urology vs pediatrics), patient demographics, VCUG outcome, and guideline adherence were evaluated with bivariate statistics and logistic regression. Subgroup analysis of patients 2-24 months was completed.

Results

VCUGs from 1,115 consecutive patients were reviewed. 747 patients were excluded (243 for known genitourinary anomalies, 262 for known VUR, 171 for antenatal hydronephrosis without UTI, and 71 for incomplete records). 368 patients (67% female, median age 12.5 months [range 4.6-49]) were included in the primary analysis. 188 patients (51%) were aged 2-24 months. VCUG ordering patterns were similar among urologists and nephrologists (35% of VCUGs) and among pediatricians and other specialists (65% of VCUGs). Thus, these specialties were grouped for analysis. 61% of VCUGs were ordered in accordance with the 2011 AAP guidelines; urologists/nephrologists were more likely to adhere to ordering guidelines than pediatricians/other specialists (76% vs 52%, OR 2.93 [1.8-4.7], p<0.0001). Subgroup analysis in patients 2-24 months revealed similar findings (76% vs 52%, OR 3.0 [1.5-6.1], p=0.002). VCUGs were abnormal in 117/368 patients (32%) overall and 49/188 (26%) patients 2-24 months. Guideline adherence was associated with increased likelihood of abnormal VCUG among all patients (36% of appropriately ordered vs. 25% of inappropriately ordered studies were abnormal, p=0.03), but there was no association in patients 2-24 months (26% of studies were abnormal in each group, p=0.98).

Conclusions

At our institution, 2011 AAP UTI guideline adherence for VCUG ordering was more likely among urologists/nephrologists than pediatricians. While adherence increased the diagnostic yield of VCUG studies in the full cohort, there was no association in children 2-24 months. Further multi-center evaluation is necessary to determine whether ordering recommendations should be revised.

Funding

None