Renal scarring in children under 36 months hospitalised for acute pyelonephritis

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Málaga, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Grupo de Investigación IBIMA, Málaga, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Departamento de Pediatría y Farmacología, Facultad de Medicina, Universidad de Málaga, Málaga, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Sección de Infectología, Unidad de Gestión Clínica de Pediatría, Hospital Regional Universitario Materno-Infantil, Málaga, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cicatrices renales en menores de 36 meses ingresados por pielonefritis aguda" ] ] "textoCompleto" => "IntroductionThe approach to the diagnosis and management of urinary tract infection (UTI) in children is complex, especially in young infants that may have especially severe forms of disease, with a high percentage of patients developing sequelae in the form of renal scarring that have variable impact in the long-term. The indications for imaging tests have been changing in recent years with the publication of different clinical guidelines.<a class="elsevierStyleCrossRefs" href="#bib0105">1–4</a> The main changes have been based on systematic literature reviews, taking into account the association of microbiological, ultrasound and cystography findings with long-term sequelae and UTI recurrence. Several practical approaches that have been proposed recently illustrate the difficulty in reaching a consensus about decision making in the management of UTIs during acute infection and after treatment to assess the impact on renal function. These approaches also identify the presence of underlying disease and prevent potential recurrences.<a class="elsevierStyleCrossRefs" href="#bib0110">2–5</a> There are few studies on this subject,<a class="elsevierStyleCrossRefs" href="#bib0130">6,7</a> especially in our region.<a class="elsevierStyleCrossRef" href="#bib0140">8</a> In this study, we reviewed the outcomes of children aged less than 36 months admitted for severe UTI, analysing the presence of renal scarring in relation to clinical manifestations, medical history and imaging test results.Patients and methodsWe conducted a retrospective study by reviewing the medical records of patients aged less than 36 months admitted to a tertiary care hospital that met the criteria for a first episode of upper urinary tract infection: probable acute pyelonephritis (APN) defined as leukocyturia and evidence of urinary pathogen growth in urine collected by catheter following previously established criteria,<a class="elsevierStyleCrossRefs" href="#bib0120">4,9</a> in the presence of fever and/or decline of general health status and/or elevated levels of acute phase reactants<a class="elsevierStyleCrossRef" href="#bib0120">4</a> (C reactive protein [CRP]>20mg/L and/or procalcitonin [PCT]>0.5ng/mL), with a minimum duration of followup of at least 6 months. The study comprehended the period between January 2010 and December 2014. The standardized antibiotherapy approach consisted of treating infants aged less than 3 months with ampicillin and gentamicin, and older children with gentamicin alone until antimicrobial susceptibility test results became available. The exclusion criteria were: UTI occurring in the context of surgery, nosocomial infection, previous or current urinary catheterization, and UTI secondary to a confirmed obstructive uropathy or limited to the lower urinary tract. We also excluded newborns aged less than 4 weeks, as UTI in these cases could be considered a manifestation of a potential generalized neonatal infection.We collected data for the following variables in each patient: age; sex; duration of symptoms in days at time of admission; fever at admission; nephrourologic abnormalities in prenatal ultrasound (dilation anywhere in the urinary tract or structural malformations); acute phase reactant levels (CRP measured by turbidimetric immunoassay; PCT measured by enzyme-linked fluorescent immunoassay, creatinine at time of admission by means of the modified Jaffé kinetic method [bichromatic spectrophotometry, 510 and 600nm]); abnormal findings in basic urinalysis; pathogen isolated in culture of urine specimen obtained by catheter; results of blood culture, urinary tract ultrasound and serial voiding cystourethrography (VCUG) performed early during admission; recurrent UTI episodes in the months following admission; and dimercaptosuccinic acid (DMSA) scintigraphy at least 6 months after the resolution of the first episode of APN.We categorized a few quantitative variables for the purpose of analysis. We divided age into three categories: less than 3 months, 3–6 months, and greater than 6 months. We categorized PCT levels into less than 0.5ng/mL, 0.5–1ng/mL, and greater than 1ng/mL. We categorized C reactive protein by quartiles. Urologic ultrasound comprised three categories: urinary tract dilation, lobar nephronia/renal abscesses, and complex malformations. The results of VCUG were divided into three categories: normal, reflux grade I–III, and reflux grade IV–V. Bacteriological results were divided into two categories: Escherichia coli (E. coli) and pathogen other than E. coli. Duration of symptoms was divided into less than one day and more than one day.Following the general guidelines that applied during the period under study,<a class="elsevierStyleCrossRefs" href="#bib0105">1,3–5</a> VCUG was indicated in patients with clinical sepsis, isolated pathogen other than E. coli, sonographic abnormalities or siblings with urinary tract abnormalities. DMSA scintigraphy was indicated in infants aged less than 6 months and all patients with abnormal ultrasound findings, pathogen other than E. coli, septic appearance, persistent fever more than 48h after initiating antibiotherapy, micturition abnormalities, dehydration or elevated creatinine at least 6 months after infection. Imaging studies were considered abnormal when cortical tracer uptake was reduced. The results were divided in two categories: normal and abnormal.We present quantitative data as mean and standard deviation, and qualitative data as frequency percentages. We analyzed the association between qualitative variables and the presence of lesions in DMSA scintigraphy by means of the χ2-test. Variables for which the association corresponded to a p-value of less than .20 were included in a binomial logistic regression analysis with the purpose of identifying independent risk factors for the presence of abnormalities in DMSA scintigraphy. We conducted the statistical analysis with the PSPP statistical software (GNU© General Public License by the Free Software Foundation).ResultsThe study included a total of 125 healthy patients. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> presents patient data for quantitative variables. Sixty percent of the patients were male; 52.8% were aged less than 3 months, 72.0% less than 6 months and 87% less than 12 months. Eight percent of cases had onset without fever. In 46.7%, symptom duration at admission was less than one day. As for diagnostic tests, the reagent strip test was positive (defined as a result corresponding to two or more crosses) for leukocyte esterase in 84% of cases, and for nitrites in 45%.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The pathogen isolated in 125 of the urine cultures was E. coli (74.6%), followed by Klebsiella pneumoniae (8.9%), Enterococcus faecalis (7.3%), Pseudomonas aeruginosa (3.2%), Proteus mirabilis (1.6%), Enterobacter cloacae (1.6%) and other. Of the total blood cultures performed (108), 7.4% were positive.Ultrasound detected nephronia, renal abscess or complex malformations in 16.7% and some type of urinary tract dilation in 21.9%. A VCUG was ordered in 70 patients; 54.3% had normal results, 12.8% had reflux grade I–III, and 32.9% reflux grade IV–V. Six patients had grade IV–V vesicoureteral reflux (VUR) with normal ultrasound results, and four of these patients developed renal scarring. Investigation with a DMSA scan was indicated in 80% of cases of APN, but was only performed in 61% of these cases due to parental non-adherence. Out of the sixty cases in which it was finally performed, some degree of renal scarring was found in 44%. In our case series, 13.4% of the patients had a history of abnormal findings in the urinary tract on prenatal ultrasound. We found a recurrence rate in the first six months of follow-up of 15.2%.<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the comparative analysis of abnormalities in the DSMA scintigraphy examination at six months. We found a statistically significant association with the presence of abnormalities in prenatal ultrasound, involvement of a pathogen other than E. coli, and recurrent UTI. We did not find an association between the presence of renal lesions and patient age or elevation of acute phase reactants.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The logistic regression analysis identified the presence of reflux of grade IV–V in VCUG and UTI recurrence as risk factors, while the peak temperature of fever was identified as a weak protective factor (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>DiscussionThe potential for developing sequelae in the form of renal scarring is the leading factor in current guidelines for deciding the diagnostic tests to be performed in cases of severe UTI, which are more frequent during childhood. Few studies make reference to the potential long-term sequelae or the probability of recurrence of these diseases in our region. Thus, we thought it would be interesting to determine the potential correlation of development of renal scarring with updated local microbiology and ultrasound and scintigraphy findings in order to establish an appropriate protocol for treatment and for determining the need for diagnostic and follow-up tests, for the purpose of optimizing long-term outcomes in adulthood while avoiding performance of unnecessary tests.There had been abnormal ultrasound findings in 38.6% of cases. Most frequent among them were nephronia and dilation of the urinary tract, which was consistent with the previous literature.<a class="elsevierStyleCrossRefs" href="#bib0150">10–15</a> The findings of DMSA scintigraphy were abnormal in 44% of the patients. Therefore, we estimated the overall percentage of patients with some type of long-term renal damage at 22%, somewhat higher than the figure reported in a previous systematic review,<a class="elsevierStyleCrossRef" href="#bib0175">15</a> although the latter included patients up to age 19 years with any type of UTI, febrile and afebrile, of whom 57% had a history of previous abnormal findings on DMSA scintigraphy. When no other indication criteria are applied, the percentage of cases of febrile UTI in which there is evidence of renal damage in acute phase DMSA scintigraphy is as high as 73%.<a class="elsevierStyleCrossRef" href="#bib0160">12</a> Case series that focus on children aged less than 36 months,<a class="elsevierStyleCrossRef" href="#bib0170">14</a> as our study did, have found a lower percentage of renal damage on DMSA scintigraphy of around 12%, but these series involved ambulatory patients and approaches in which the sole indication for DMSA scintigraphy is the presence of abnormal findings in ultrasound. In our opinion, this results in a clear selection bias, and we believe that other criteria such as those applied in our study should be indications for DMSA scintigraphy.<a class="elsevierStyleCrossRef" href="#bib0120">4</a> We also attribute the incidence of scarring that we found to the sample selected for our study, with a predominance of young infants with probable APN that presented with fever and a marked elevation of acute phase reactants. Although PCT has been described as a marker of renal damage with development of scarring in the long term,<a class="elsevierStyleCrossRef" href="#bib0180">16</a> we did not find this association in our series. In this regard, there is no wide consensus regarding the routine measurement of acute phase reactants for assessment of acute disease.<a class="elsevierStyleCrossRef" href="#bib0150">10</a> In research on infants with febrile UTI, DMSA scintigraphy showed renal lesions at 3 months in 51% of the patients, while VUR was found in 25%.<a class="elsevierStyleCrossRef" href="#bib0155">11</a> It is possible that some of the lesions detected by DMSA scintigraphy will have no long-term impact, as suggested by some authors,<a class="elsevierStyleCrossRef" href="#bib0155">11</a> but the circumstances under which this test can be forgone have yet to be established.In our case series, the association between abnormal findings in VCUG and high-grade (IV–V) reflux and DMSA scan abnormalities remained significant in the multivariate analysis, suggesting that reflux is a predisposing factor for APN but that the latter, in itself, can account for renal scarring regardless of its cause. The authors of the systematic review referred above noted that the presumed association of VCUG and DMSA gammagraphy could be due to confounding factors,<a class="elsevierStyleCrossRef" href="#bib0175">15</a> as nearly all studies find that high-grade reflux is found in only approximately 2.5% of cases of APN, and yet the mean percentage of cases with sequelae detected by DMSA gammagraphy is 25%. In our series, the association emerged as an independent factor in the logistic regression analysis (OR, 6.419). For decades, the presence of VUR has been the focus of interest in the follow-up of UTI, although it is evident that the presence of VUR is neither necessary nor sufficient to develop renal scarring.<a class="elsevierStyleCrossRef" href="#bib0170">14</a>The absence of an association between the development of scarring and isolation of a bacterium other than E. coli in the multivariate analysis is consistent with the recommendations of the most recent clinical practice guidelines for the management of UTI in children, according to which the results of microbial testing are no longer a criteria for the indication of VCUG.<a class="elsevierStyleCrossRefs" href="#bib0105">1,2,4,5</a> Perhaps the criterion of the involved bacterium for the indication of DMSA scintigraphy should also be reconsidered.There has been previous discussion that the association between the abnormalities found in prenatal ultrasound and DMSA scintigraphy may result from a cause of cortical dysplasia that predated UTI and manifests with renal damage detectable in DMSA scintigraphy that may progress to renal failure regardless of the subsequent treatment of the associated VUR, which is usually of a high grade.<a class="elsevierStyleCrossRefs" href="#bib0185">17,18</a> A larger sample of cases may be able to evince the association that is suggested by the χ2-test.As reported in other series, we found a statistically significant association between recurrence of APN and renal damage, and recurrence was identified as a risk factor (OR, 7.52). We do not know the role that the genetic susceptibility to UTI previously described in the literature<a class="elsevierStyleCrossRef" href="#bib0195">19</a> may have played in our series. In this regard, the best preventive measure is early detection of reinfection and its prompt treatment, as has been proposed,<a class="elsevierStyleCrossRefs" href="#bib0105">1,4,5</a> while the need for antibiotic prophylaxis in reflux cases is increasingly disputed.<a class="elsevierStyleCrossRefs" href="#bib0125">5,20</a>Lastly, we would like to mention the protective effect (albeit a weak one) of fever in relation to the development of scarring, as a mechanism that is a nonspecific response to infection. We have not found any studies that analyzed or referred to this aspect.Some of the limitations of the study were the lack of long-term follow-up of the impact of the detected renal scarring, as well as the lack of data on recurrence beyond the first six months from the first episode of APN. The sample consisted of severe cases with a predominance of infants younger than 6 months of age with a marked elevation of acute phase reactants, and thus our conclusions apply to this specific subset of patients with APN, on whom, as we mentioned before, few data are available.ConclusionsThe presence of renal scarring at 6 months reached 44% with the selection criteria for DMSA scintigraphy applied in our study of patients hospitalised with severe disease. In our study, recurrence and high-grade VUR were risk factors for abnormal DMSA scintigraphy findings. Raised body temperature in the fever variable appeared as a weak protective factor. We did not find an association with the isolation of pathogens other than E. coli. We think it is justified to propose eliminating the isolation of a pathogen other than E. coli as an indication for ordering a DMSA scan.Conflict of interestsThe authors have no conflict of interests to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres794527" "titulo" => "Abstract" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objectives" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Method" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec792850" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres794526" "titulo" => "Resumen" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivos" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Método" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec792851" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Patients and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interests" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-12-22" "fechaAceptado" => "2016-03-01" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec792850" "palabras" => array:4 [ 0 => "Renal scar" 1 => "Pyelonephritis" 2 => "Voiding cystourethrography" 3 => "DMSA-scintigraphy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec792851" "palabras" => array:4 [ 0 => "Cicatriz renal" 1 => "Pielonefritis" 2 => "Cistourografía miccional seriada" 3 => "Gammagrafía DMSA" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionAcute pyelonephritis (APN) is one of the most common causes of serious bacterial infection in infants. Renal scarring is the most prevalent long-term complication. ObjectivesTo review the incidence of renal scarring within 6 months after an episode of APN in children under 36 months and its relationship with imaging studies, clinical settings, and bacteriology. MethodA retrospective study of previously healthy patients aged one to 36 months, admitted for a first episode of APN, with a minimum follow-up of 6 months. Demographic and clinical variables were collected along with bacteriology, renal and bladder ultrasound scan, voiding cystourethrography, DMSA-scintigraphy, and re-infection events. ResultsA total of 125 patients were included in the study, of which 60% were male, the large majority (92%) febrile, and due to Escherichia coli (74.6%). There was a history of prenatal ultrasound scan changes in 15.4%. Ultrasound scan found dilation of the urinary tract in 22.1%. Voiding cystourethrography was performed on 70 patients: 54.3% no abnormalities, 12.8% vesicoureteral reflux (VUR) grade i-iii, and 32.9% iv-v grade VUR. Six patients had iv-v grade VUR with a normal ultrasound scan. Adherence to DMSA-scintigraphy at 6 months was only 61% of that indicated. Renal scarring was found in 44.3% of those in which it was performed (60 cases). ConclusionsAlmost half (44%) DMSA-scintigraphy in children aged one to 36 months hospitalised for APN show renal scarring at 6 months, which was found to be associated with the re-infection events and the iv-v grade VUR. There was no relationship between scarring and the bacteriology or the elevations of inflammatory biochemical markers." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objectives" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Method" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónUna de las causas más frecuentes de infección bacteriana grave en lactantes es la pielonefritis aguda (PNFA), cuya secuela más prevalente a largo plazo es la instauración de cicatrices renales. ObjetivosRevisar la incidencia de cicatrices renales a los 6 meses de un episodio de PNFA en niños menores de 36 meses y su relación con la clínica, las pruebas de imagen y la bacteriología. MétodoEstudio retrospectivo de pacientes de uno a 36 meses previamente sanos ingresados por un primer episodio de PNFA, con un seguimiento mínimo de 6 meses. Se recogieron las variables demográficas junto con bacteriología, ecografía, cistourografía miccional seriada, recidivas y gammagrafía-DMSA. ResultadosSe incluyeron 125 pacientes, 60% varones, la mayoría febriles al ingreso (92%), debido a E. coli (74,6%). Existía antecedente de alteración ecográfica prenatal solo en el 15,4%. La ecografía detectó dilatación de la vía urinaria en el 22,1%. En 70 pacientes se indicó cistourografía miccional seriada: 54,3% sin anomalías, 12,8% con reflujo vesicoureteral (RVU) grado i-iii y 32,9% con RVU iv-v. Seis pacientes presentaban RVU iv-v con ecografías normales. La adherencia a la gammagrafía DMSA a los 6 meses fue solo del 61% de los indicados. De los efectuados (60 casos), en un 44,3% se hallaron cicatrices renales, relacionadas significativamente con la recurrencia y el RVU iv-v, pero no con la bacteriología ni con la elevación de reactantes. ConclusionesEl 44% de las gammagrafías-DMSA de pacientes de uno a 36 meses hospitalizados por PNFA desarrolla cicatrices renales a los 6 meses. Estas se relacionaron con las recurrencias y el RVU grave, pero no con la bacteriología y los reactantes inflamatorios." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivos" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Método" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Rodríguez-Azor B, Ramos-Fernández JM, Sánchiz-Cárdenas S, Cordón-Martínez A, Carazo-Gallego B, Moreno-Pérez D, et al. Cicatrices renales en menores de 36 meses ingresados por pielonefritis aguda. An Pediatr (Barc). 2017;86:76–80." ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">N \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Minimum \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Maximum \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Standard deviation \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age (months) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">125 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.68 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fever (°C) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">120 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38.87 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.84 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Duration of symptoms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">117 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.53 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.42 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">C reactive protein (mg/L) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">121 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">358 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">98.85 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">82.35 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Procalcitonin (ng/mL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">86 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">79 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.82 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Plasma creatinine (mg/dL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">87 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.22 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1328982.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Main descriptive statistical results for the data collected at the time of hospital admission for the first episode of upper urinary tract infection." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "CRP, C reactive protein; PCT, procalcitonin; VCUG: voiding cystourethrography." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.490 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prenatal ultrasound: abnormal findings \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.007 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fever \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.007 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Duration of symptoms (days) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.089 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PCT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.377 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CRP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.973 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Leukocyturia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.396 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nitrituria \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.107 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bacteriuria \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.770 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pathogen other than E. coli \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.002 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ultrasound at diagnosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Serial VCUG \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Recurrence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1328981.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Statistical significance of comparison by χ2 test of abnormal dimercaptosuccinic acid scintigraphy findings and other variables under study." ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "CI, confidence interval; OR: odds ratio; VCUG: voiding cystourethrography; VUR, vesicoureteral reflux." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Significance: p \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">OR \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">95% CI \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fever \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.005 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.967 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.945–0.990 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">VCUG: VUR grade IV–V \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.006 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.419 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.688–24.413 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Recurrence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.017 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.592 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.433–40.213 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1328980.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Variables that were statistically significant in the logistic regression analysis, odds ratio and 95% confidence interval." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib0105" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Technical report – diagnosis and management of an initial UTI in febrile infants and young children" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S.M. 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Original Article

Renal scarring in children under 36 months hospitalised for acute pyelonephritis

Cicatrices renales en menores de 36 meses ingresados por pielonefritis aguda

Begoña Rodríguez-Azora, José Miguel Ramos-Fernándezb,c,

Corresponding author

dr.jmramos@gmail.com
josem.ramos.sspa@juntadeandalucia.es

Corresponding author.

, Sonia Sánchiz-Cárdenasa, Ana Cordón-Martínezb, Begoña Carazo-Gallegoe, David Moreno-Pérezc,d,e, Antonio Urda-Cardonaa

a Unidad de Gestión Clínica de Pediatría, Hospital Materno-Infantil, Hospital Regional Universitario de Málaga, Málaga, Spain

b Sección de Lactantes, Unidad de Gestión Clínica de Pediatría, Hospital Materno-Infantil, Hospital Regional Universitario de Málaga, Spain

c Grupo de Investigación IBIMA, Málaga, Spain

d Departamento de Pediatría y Farmacología, Facultad de Medicina, Universidad de Málaga, Málaga, Spain

e Sección de Infectología, Unidad de Gestión Clínica de Pediatría, Hospital Regional Universitario Materno-Infantil, Málaga, Spain

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        "titulo" => "Cicatrices renales en menores de 36 meses ingresados por pielonefritis aguda"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The approach to the diagnosis and management of urinary tract infection &#40;UTI&#41; in children is complex&#44; especially in young infants that may have especially severe forms of disease&#44; with a high percentage of patients developing sequelae in the form of renal scarring that have variable impact in the long-term&#46; The indications for imaging tests have been changing in recent years with the publication of different clinical guidelines&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1&#8211;4</span></a> The main changes have been based on systematic literature reviews&#44; taking into account the association of microbiological&#44; ultrasound and cystography findings with long-term sequelae and UTI recurrence&#46; Several practical approaches that have been proposed recently illustrate the difficulty in reaching a consensus about decision making in the management of UTIs during acute infection and after treatment to assess the impact on renal function&#46; These approaches also identify the presence of underlying disease and prevent potential recurrences&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">2&#8211;5</span></a> There are few studies on this subject&#44;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#44;7</span></a> especially in our region&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a> In this study&#44; we reviewed the outcomes of children aged less than 36 months admitted for severe UTI&#44; analysing the presence of renal scarring in relation to clinical manifestations&#44; medical history and imaging test results&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Patients and methods</span><p id="par0010" class="elsevierStylePara elsevierViewall">We conducted a retrospective study by reviewing the medical records of patients aged less than 36 months admitted to a tertiary care hospital that met the criteria for a first episode of upper urinary tract infection&#58; probable acute pyelonephritis &#40;APN&#41; defined as leukocyturia and evidence of urinary pathogen growth in urine collected by catheter following previously established criteria&#44;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">4&#44;9</span></a> in the presence of fever and&#47;or decline of general health status and&#47;or elevated levels of acute phase reactants<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a> &#40;C reactive protein &#91;CRP&#93;<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>mg&#47;L and&#47;or procalcitonin &#91;PCT&#93;<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;5<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#41;&#44; with a minimum duration of followup of at least 6 months&#46; The study comprehended the period between January 2010 and December 2014&#46; The standardized antibiotherapy approach consisted of treating infants aged less than 3 months with ampicillin and gentamicin&#44; and older children with gentamicin alone until antimicrobial susceptibility test results became available&#46; The exclusion criteria were&#58; UTI occurring in the context of surgery&#44; nosocomial infection&#44; previous or current urinary catheterization&#44; and UTI secondary to a confirmed obstructive uropathy or limited to the lower urinary tract&#46; We also excluded newborns aged less than 4 weeks&#44; as UTI in these cases could be considered a manifestation of a potential generalized neonatal infection&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">We collected data for the following variables in each patient&#58; age&#59; sex&#59; duration of symptoms in days at time of admission&#59; fever at admission&#59; nephrourologic abnormalities in prenatal ultrasound &#40;dilation anywhere in the urinary tract or structural malformations&#41;&#59; acute phase reactant levels &#40;CRP measured by turbidimetric immunoassay&#59; PCT measured by enzyme-linked fluorescent immunoassay&#44; creatinine at time of admission by means of the modified Jaff&#233; kinetic method &#91;bichromatic spectrophotometry&#44; 510 and 600<span class="elsevierStyleHsp" style=""></span>nm&#93;&#41;&#59; abnormal findings in basic urinalysis&#59; pathogen isolated in culture of urine specimen obtained by catheter&#59; results of blood culture&#44; urinary tract ultrasound and serial voiding cystourethrography &#40;VCUG&#41; performed early during admission&#59; recurrent UTI episodes in the months following admission&#59; and dimercaptosuccinic acid &#40;DMSA&#41; scintigraphy at least 6 months after the resolution of the first episode of APN&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">We categorized a few quantitative variables for the purpose of analysis&#46; We divided age into three categories&#58; less than 3 months&#44; 3&#8211;6 months&#44; and greater than 6 months&#46; We categorized PCT levels into less than 0&#46;5<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#44; 0&#46;5&#8211;1<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#44; and greater than 1<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#46; We categorized C reactive protein by quartiles&#46; Urologic ultrasound comprised three categories&#58; urinary tract dilation&#44; lobar nephronia&#47;renal abscesses&#44; and complex malformations&#46; The results of VCUG were divided into three categories&#58; normal&#44; reflux grade I&#8211;III&#44; and reflux grade IV&#8211;V&#46; Bacteriological results were divided into two categories&#58; <span class="elsevierStyleItalic">Escherichia coli &#40;E&#46; coli&#41;</span> and pathogen other than <span class="elsevierStyleItalic">E&#46; coli</span>&#46; Duration of symptoms was divided into less than one day and more than one day&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Following the general guidelines that applied during the period under study&#44;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1&#44;3&#8211;5</span></a> VCUG was indicated in patients with clinical sepsis&#44; isolated pathogen other than <span class="elsevierStyleItalic">E&#46; coli</span>&#44; sonographic abnormalities or siblings with urinary tract abnormalities&#46; DMSA scintigraphy was indicated in infants aged less than 6 months and all patients with abnormal ultrasound findings&#44; pathogen other than <span class="elsevierStyleItalic">E&#46; coli</span>&#44; septic appearance&#44; persistent fever more than 48<span class="elsevierStyleHsp" style=""></span>h after initiating antibiotherapy&#44; micturition abnormalities&#44; dehydration or elevated creatinine at least 6 months after infection&#46; Imaging studies were considered abnormal when cortical tracer uptake was reduced&#46; The results were divided in two categories&#58; normal and abnormal&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">We present quantitative data as mean and standard deviation&#44; and qualitative data as frequency percentages&#46; We analyzed the association between qualitative variables and the presence of lesions in DMSA scintigraphy by means of the <span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span>-test&#46; Variables for which the association corresponded to a <span class="elsevierStyleItalic">p</span>-value of less than &#46;20 were included in a binomial logistic regression analysis with the purpose of identifying independent risk factors for the presence of abnormalities in DMSA scintigraphy&#46; We conducted the statistical analysis with the PSPP statistical software &#40;GNU<span class="elsevierStyleSup">&#169;</span> General Public License by the Free Software Foundation&#41;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0035" class="elsevierStylePara elsevierViewall">The study included a total of 125 healthy patients&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> presents patient data for quantitative variables&#46; Sixty percent of the patients were male&#59; 52&#46;8&#37; were aged less than 3 months&#44; 72&#46;0&#37; less than 6 months and 87&#37; less than 12 months&#46; Eight percent of cases had onset without fever&#46; In 46&#46;7&#37;&#44; symptom duration at admission was less than one day&#46; As for diagnostic tests&#44; the reagent strip test was positive &#40;defined as a result corresponding to two or more crosses&#41; for leukocyte esterase in 84&#37; of cases&#44; and for nitrites in 45&#37;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">The pathogen isolated in 125 of the urine cultures was <span class="elsevierStyleItalic">E&#46; coli</span> &#40;74&#46;6&#37;&#41;&#44; followed by <span class="elsevierStyleItalic">Klebsiella pneumoniae</span> &#40;8&#46;9&#37;&#41;&#44; <span class="elsevierStyleItalic">Enterococcus faecalis</span> &#40;7&#46;3&#37;&#41;&#44; <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> &#40;3&#46;2&#37;&#41;&#44; <span class="elsevierStyleItalic">Proteus mirabilis</span> &#40;1&#46;6&#37;&#41;&#44; <span class="elsevierStyleItalic">Enterobacter cloacae</span> &#40;1&#46;6&#37;&#41; and other&#46; Of the total blood cultures performed &#40;108&#41;&#44; 7&#46;4&#37; were positive&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Ultrasound detected nephronia&#44; renal abscess or complex malformations in 16&#46;7&#37; and some type of urinary tract dilation in 21&#46;9&#37;&#46; A VCUG was ordered in 70 patients&#59; 54&#46;3&#37; had normal results&#44; 12&#46;8&#37; had reflux grade I&#8211;III&#44; and 32&#46;9&#37; reflux grade IV&#8211;V&#46; Six patients had grade IV&#8211;V vesicoureteral reflux &#40;VUR&#41; with normal ultrasound results&#44; and four of these patients developed renal scarring&#46; Investigation with a DMSA scan was indicated in 80&#37; of cases of APN&#44; but was only performed in 61&#37; of these cases due to parental non-adherence&#46; Out of the sixty cases in which it was finally performed&#44; some degree of renal scarring was found in 44&#37;&#46; In our case series&#44; 13&#46;4&#37; of the patients had a history of abnormal findings in the urinary tract on prenatal ultrasound&#46; We found a recurrence rate in the first six months of follow-up of 15&#46;2&#37;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the comparative analysis of abnormalities in the DSMA scintigraphy examination at six months&#46; We found a statistically significant association with the presence of abnormalities in prenatal ultrasound&#44; involvement of a pathogen other than <span class="elsevierStyleItalic">E&#46; coli</span>&#44; and recurrent UTI&#46; We did not find an association between the presence of renal lesions and patient age or elevation of acute phase reactants&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The logistic regression analysis identified the presence of reflux of grade IV&#8211;V in VCUG and UTI recurrence as risk factors&#44; while the peak temperature of fever was identified as a weak protective factor &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">The potential for developing sequelae in the form of renal scarring is the leading factor in current guidelines for deciding the diagnostic tests to be performed in cases of severe UTI&#44; which are more frequent during childhood&#46; Few studies make reference to the potential long-term sequelae or the probability of recurrence of these diseases in our region&#46; Thus&#44; we thought it would be interesting to determine the potential correlation of development of renal scarring with updated local microbiology and ultrasound and scintigraphy findings in order to establish an appropriate protocol for treatment and for determining the need for diagnostic and follow-up tests&#44; for the purpose of optimizing long-term outcomes in adulthood while avoiding performance of unnecessary tests&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">There had been abnormal ultrasound findings in 38&#46;6&#37; of cases&#46; Most frequent among them were nephronia and dilation of the urinary tract&#44; which was consistent with the previous literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">10&#8211;15</span></a> The findings of DMSA scintigraphy were abnormal in 44&#37; of the patients&#46; Therefore&#44; we estimated the overall percentage of patients with some type of long-term renal damage at 22&#37;&#44; somewhat higher than the figure reported in a previous systematic review&#44;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">15</span></a> although the latter included patients up to age 19 years with any type of UTI&#44; febrile and afebrile&#44; of whom 57&#37; had a history of previous abnormal findings on DMSA scintigraphy&#46; When no other indication criteria are applied&#44; the percentage of cases of febrile UTI in which there is evidence of renal damage in acute phase DMSA scintigraphy is as high as 73&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> Case series that focus on children aged less than 36 months&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a> as our study did&#44; have found a lower percentage of renal damage on DMSA scintigraphy of around 12&#37;&#44; but these series involved ambulatory patients and approaches in which the sole indication for DMSA scintigraphy is the presence of abnormal findings in ultrasound&#46; In our opinion&#44; this results in a clear selection bias&#44; and we believe that other criteria such as those applied in our study should be indications for DMSA scintigraphy&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a> We also attribute the incidence of scarring that we found to the sample selected for our study&#44; with a predominance of young infants with probable APN that presented with fever and a marked elevation of acute phase reactants&#46; Although PCT has been described as a marker of renal damage with development of scarring in the long term&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">16</span></a> we did not find this association in our series&#46; In this regard&#44; there is no wide consensus regarding the routine measurement of acute phase reactants for assessment of acute disease&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a> In research on infants with febrile UTI&#44; DMSA scintigraphy showed renal lesions at 3 months in 51&#37; of the patients&#44; while VUR was found in 25&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a> It is possible that some of the lesions detected by DMSA scintigraphy will have no long-term impact&#44; as suggested by some authors&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a> but the circumstances under which this test can be forgone have yet to be established&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">In our case series&#44; the association between abnormal findings in VCUG and high-grade &#40;IV&#8211;V&#41; reflux and DMSA scan abnormalities remained significant in the multivariate analysis&#44; suggesting that reflux is a predisposing factor for APN but that the latter&#44; in itself&#44; can account for renal scarring regardless of its cause&#46; The authors of the systematic review referred above noted that the presumed association of VCUG and DMSA gammagraphy could be due to confounding factors&#44;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">15</span></a> as nearly all studies find that high-grade reflux is found in only approximately 2&#46;5&#37; of cases of APN&#44; and yet the mean percentage of cases with sequelae detected by DMSA gammagraphy is 25&#37;&#46; In our series&#44; the association emerged as an independent factor in the logistic regression analysis &#40;OR&#44; 6&#46;419&#41;&#46; For decades&#44; the presence of VUR has been the focus of interest in the follow-up of UTI&#44; although it is evident that the presence of VUR is neither necessary nor sufficient to develop renal scarring&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The absence of an association between the development of scarring and isolation of a bacterium other than <span class="elsevierStyleItalic">E&#46; coli</span> in the multivariate analysis is consistent with the recommendations of the most recent clinical practice guidelines for the management of UTI in children&#44; according to which the results of microbial testing are no longer a criteria for the indication of VCUG&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1&#44;2&#44;4&#44;5</span></a> Perhaps the criterion of the involved bacterium for the indication of DMSA scintigraphy should also be reconsidered&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">There has been previous discussion that the association between the abnormalities found in prenatal ultrasound and DMSA scintigraphy may result from a cause of cortical dysplasia that predated UTI and manifests with renal damage detectable in DMSA scintigraphy that may progress to renal failure regardless of the subsequent treatment of the associated VUR&#44; which is usually of a high grade&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">17&#44;18</span></a> A larger sample of cases may be able to evince the association that is suggested by the &#967;<span class="elsevierStyleSup">2</span>-test&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">As reported in other series&#44; we found a statistically significant association between recurrence of APN and renal damage&#44; and recurrence was identified as a risk factor &#40;OR&#44; 7&#46;52&#41;&#46; We do not know the role that the genetic susceptibility to UTI previously described in the literature<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">19</span></a> may have played in our series&#46; In this regard&#44; the best preventive measure is early detection of reinfection and its prompt treatment&#44; as has been proposed&#44;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1&#44;4&#44;5</span></a> while the need for antibiotic prophylaxis in reflux cases is increasingly disputed&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">5&#44;20</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Lastly&#44; we would like to mention the protective effect &#40;albeit a weak one&#41; of fever in relation to the development of scarring&#44; as a mechanism that is a nonspecific response to infection&#46; We have not found any studies that analyzed or referred to this aspect&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Some of the limitations of the study were the lack of long-term follow-up of the impact of the detected renal scarring&#44; as well as the lack of data on recurrence beyond the first six months from the first episode of APN&#46; The sample consisted of severe cases with a predominance of infants younger than 6 months of age with a marked elevation of acute phase reactants&#44; and thus our conclusions apply to this specific subset of patients with APN&#44; on whom&#44; as we mentioned before&#44; few data are available&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusions</span><p id="par0100" class="elsevierStylePara elsevierViewall">The presence of renal scarring at 6 months reached 44&#37; with the selection criteria for DMSA scintigraphy applied in our study of patients hospitalised with severe disease&#46; In our study&#44; recurrence and high-grade VUR were risk factors for abnormal DMSA scintigraphy findings&#46; Raised body temperature in the fever variable appeared as a weak protective factor&#46; We did not find an association with the isolation of pathogens other than <span class="elsevierStyleItalic">E&#46; coli</span>&#46; We think it is justified to propose eliminating the isolation of a pathogen other than <span class="elsevierStyleItalic">E&#46; coli</span> as an indication for ordering a DMSA scan&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflict of interests</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec792850"
          "palabras" => array:4 [
            0 => "Renal scar"
            1 => "Pyelonephritis"
            2 => "Voiding cystourethrography"
            3 => "DMSA-scintigraphy"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec792851"
          "palabras" => array:4 [
            0 => "Cicatriz renal"
            1 => "Pielonefritis"
            2 => "Cistourograf&#237;a miccional seriada"
            3 => "Gammagraf&#237;a DMSA"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Acute pyelonephritis &#40;APN&#41; is one of the most common causes of serious bacterial infection in infants&#46; Renal scarring is the most prevalent long-term complication&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objectives</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To review the incidence of renal scarring within 6 months after an episode of APN in children under 36 months and its relationship with imaging studies&#44; clinical settings&#44; and bacteriology&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Method</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A retrospective study of previously healthy patients aged one to 36 months&#44; admitted for a first episode of APN&#44; with a minimum follow-up of 6 months&#46; Demographic and clinical variables were collected along with bacteriology&#44; renal and bladder ultrasound scan&#44; voiding cystourethrography&#44; DMSA-scintigraphy&#44; and re-infection events&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A total of 125 patients were included in the study&#44; of which 60&#37; were male&#44; the large majority &#40;92&#37;&#41; febrile&#44; and due to <span class="elsevierStyleItalic">Escherichia coli</span> &#40;74&#46;6&#37;&#41;&#46; There was a history of prenatal ultrasound scan changes in 15&#46;4&#37;&#46; Ultrasound scan found dilation of the urinary tract in 22&#46;1&#37;&#46; Voiding cystourethrography was performed on 70 patients&#58; 54&#46;3&#37; no abnormalities&#44; 12&#46;8&#37; vesicoureteral reflux &#40;VUR&#41; grade <span class="elsevierStyleSmallCaps">i</span>-<span class="elsevierStyleSmallCaps">iii</span>&#44; and 32&#46;9&#37; <span class="elsevierStyleSmallCaps">iv</span>-<span class="elsevierStyleSmallCaps">v</span> grade VUR&#46; Six patients had <span class="elsevierStyleSmallCaps">iv</span>-<span class="elsevierStyleSmallCaps">v</span> grade VUR with a normal ultrasound scan&#46; Adherence to DMSA-scintigraphy at 6 months was only 61&#37; of that indicated&#46; Renal scarring was found in 44&#46;3&#37; of those in which it was performed &#40;60 cases&#41;&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Almost half &#40;44&#37;&#41; DMSA-scintigraphy in children aged one to 36 months hospitalised for APN show renal scarring at 6 months&#44; which was found to be associated with the re-infection events and the <span class="elsevierStyleSmallCaps">iv</span>-<span class="elsevierStyleSmallCaps">v</span> grade VUR&#46; There was no relationship between scarring and the bacteriology or the elevations of inflammatory biochemical markers&#46;</p></span>"
        "secciones" => array:5 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Objectives"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Method"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Results"
          ]
          4 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Conclusions"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Una de las causas m&#225;s frecuentes de infecci&#243;n bacteriana grave en lactantes es la pielonefritis aguda &#40;PNFA&#41;&#44; cuya secuela m&#225;s prevalente a largo plazo es la instauraci&#243;n de cicatrices renales&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Revisar la incidencia de cicatrices renales a los 6 meses de un episodio de PNFA en ni&#241;os menores de 36 meses y su relaci&#243;n con la cl&#237;nica&#44; las pruebas de imagen y la bacteriolog&#237;a&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">M&#233;todo</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo de pacientes de uno a 36 meses previamente sanos ingresados por un primer episodio de PNFA&#44; con un seguimiento m&#237;nimo de 6 meses&#46; Se recogieron las variables demogr&#225;ficas junto con bacteriolog&#237;a&#44; ecograf&#237;a&#44; cistourograf&#237;a miccional seriada&#44; recidivas y gammagraf&#237;a-DMSA&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 125 pacientes&#44; 60&#37; varones&#44; la mayor&#237;a febriles al ingreso &#40;92&#37;&#41;&#44; debido a <span class="elsevierStyleItalic">E&#46; coli</span> &#40;74&#44;6&#37;&#41;&#46; Exist&#237;a antecedente de alteraci&#243;n ecogr&#225;fica prenatal solo en el 15&#44;4&#37;&#46; La ecograf&#237;a detect&#243; dilataci&#243;n de la v&#237;a urinaria en el 22&#44;1&#37;&#46; En 70 pacientes se indic&#243; cistourograf&#237;a miccional seriada&#58; 54&#44;3&#37; sin anomal&#237;as&#44; 12&#44;8&#37; con reflujo vesicoureteral &#40;RVU&#41; grado <span class="elsevierStyleSmallCaps">i</span>-<span class="elsevierStyleSmallCaps">iii</span> y 32&#44;9&#37; con RVU <span class="elsevierStyleSmallCaps">iv</span>-<span class="elsevierStyleSmallCaps">v</span>&#46; Seis pacientes presentaban RVU <span class="elsevierStyleSmallCaps">iv</span>-<span class="elsevierStyleSmallCaps">v</span> con ecograf&#237;as normales&#46; La adherencia a la gammagraf&#237;a DMSA a los 6 meses fue solo del 61&#37; de los indicados&#46; De los efectuados &#40;60 casos&#41;&#44; en un 44&#44;3&#37; se hallaron cicatrices renales&#44; relacionadas significativamente con la recurrencia y el RVU <span class="elsevierStyleSmallCaps">iv</span>-<span class="elsevierStyleSmallCaps">v&#44;</span> pero no con la bacteriolog&#237;a ni con la elevaci&#243;n de reactantes&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">El 44&#37; de las gammagraf&#237;as-DMSA de pacientes de uno a 36 meses hospitalizados por PNFA desarrolla cicatrices renales a los 6 meses&#46; Estas se relacionaron con las recurrencias y el RVU grave&#44; pero no con la bacteriolog&#237;a y los reactantes inflamatorios&#46;</p></span>"
        "secciones" => array:5 [
          0 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Introducci&#243;n"
          ]
          1 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Objetivos"
          ]
          2 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "M&#233;todo"
          ]
          3 => array:2 [
            "identificador" => "abst0045"
            "titulo" => "Resultados"
          ]
          4 => array:2 [
            "identificador" => "abst0050"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Rodr&#237;guez-Azor B&#44; Ramos-Fern&#225;ndez JM&#44; S&#225;nchiz-C&#225;rdenas S&#44; Cord&#243;n-Mart&#237;nez A&#44; Carazo-Gallego B&#44; Moreno-P&#233;rez D&#44; et al&#46; Cicatrices renales en menores de 36 meses ingresados por pielonefritis aguda&#46; An Pediatr &#40;Barc&#41;&#46; 2017&#59;86&#58;76&#8211;80&#46;</p>"
      ]
    ]
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Minimum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Maximum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Standard deviation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age &#40;months&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">125&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;68&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fever &#40;&#176;C&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">120&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38&#46;87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Duration of symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">117&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">C reactive protein &#40;mg&#47;L&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">121&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">358&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">98&#46;85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">82&#46;35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Procalcitonin &#40;ng&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Plasma creatinine &#40;mg&#47;dL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Main descriptive statistical results for the data collected at the time of hospital admission for the first episode of upper urinary tract infection&#46;</p>"
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">CRP&#44; C reactive protein&#59; PCT&#44; procalcitonin&#59; VCUG&#58; voiding cystourethrography&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;490&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prenatal ultrasound&#58; abnormal findings&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;007&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fever&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;007&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Duration of symptoms &#40;days&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;089&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PCT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;377&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CRP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;973&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Leukocyturia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;396&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nitrituria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;107&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bacteriuria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;770&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pathogen other than <span class="elsevierStyleItalic">E&#46; coli</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ultrasound at diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Serial VCUG&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 23412879
Original language: English

DOI:10.1016/j.anpede.2016.03.008

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Year/Month	Html	Pdf	Total

2024 November	14	18	32
2024 October	100	36	136
2024 September	141	34	175
2024 August	141	61	202
2024 July	166	41	207
2024 June	159	33	192
2024 May	136	36	172
2024 April	114	34	148
2024 March	93	24	117
2024 February	110	33	143
2024 January	129	22	151
2023 December	130	26	156
2023 November	115	25	140
2023 October	123	23	146
2023 September	107	19	126
2023 August	98	16	114
2023 July	98	22	120
2023 June	111	27	138
2023 May	127	23	150
2023 April	94	25	119
2023 March	128	24	152
2023 February	76	15	91
2023 January	96	27	123
2022 December	78	27	105
2022 November	83	37	120
2022 October	93	61	154
2022 September	78	26	104
2022 August	70	72	142
2022 July	63	47	110
2022 June	64	38	102
2022 May	55	42	97
2022 April	77	23	100
2022 March	142	49	191
2022 February	89	43	132
2022 January	102	39	141
2021 December	84	49	133
2021 November	88	47	135
2021 October	142	76	218
2021 September	75	37	112
2021 August	103	44	147
2021 July	73	37	110
2021 June	97	53	150
2021 May	108	42	150
2021 April	308	93	401
2021 March	205	29	234
2021 February	148	29	177
2021 January	137	47	184
2020 December	90	24	114
2020 November	86	21	107
2020 October	67	15	82
2020 September	50	26	76
2020 August	50	16	66
2020 July	53	19	72
2020 June	44	16	60
2020 May	46	22	68
2020 April	37	23	60
2020 March	38	17	55
2020 February	31	19	50
2020 January	35	24	59
2019 December	52	27	79
2019 November	39	18	57
2019 October	37	14	51
2019 September	55	24	79
2019 August	59	26	85
2019 July	28	26	54
2019 June	27	21	48
2019 May	69	23	92
2019 April	87	18	105
2019 March	44	11	55
2019 February	43	18	61
2019 January	39	20	59
2018 December	47	31	78
2018 November	86	32	118
2018 October	174	19	193
2018 September	61	5	66
2018 August	1	0	1
2018 July	2	0	2
2018 June	3	0	3
2018 May	4	0	4
2018 April	22	0	22
2018 March	27	0	27
2018 February	12	0	12
2018 January	21	0	21
2017 December	24	0	24
2017 November	13	0	13
2017 October	18	0	18
2017 September	17	0	17
2017 August	17	0	17
2017 July	23	0	23
2017 June	28	21	49
2017 May	27	10	37
2017 April	110	89	199
2017 March	17	25	42
2017 February	27	28	55
2017 January	7	19	26
2016 December	0	1	1

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