Top-Down Versus Bottom-Up Approach in Children Presented With Urinary Tract Infection- Comparative Effectiveness Analysis Using RIVUR and CUTIE Data.

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The initial imaging approach to children with urinary tract infection (UTI) is controversial. Along with renal/bladder ultrasound, some advocate VCUG (bottom-up approach) while others advocate DMSA (top-down approach). Comparison of these approaches is challenging. In RIVUR/CUTIE trials, however, all subjects underwent both VCUG and DMSA. Our objective was to perform a comparative effectiveness analysis of the bottom-up vs. top-down approach.We simulated 1,000 hypothetical sets of 500 children using RIVUR/CUTIE data. In top-down approach, patients underwent initial DMSA, and only those with renal scarring underwent VCUG. In bottom-up approach, the initial study was VCUG. We assumed all VUR children received continuous antibiotic prophylaxis (CAP). Outcomes included recurrent UTI(rUTI), number of VCUGs, and CAP exposure. We assumed a 25% VUR prevalence in children with initial UTI with sensitivity analysis using 40% VUR prevalence.Median age of original RIVUR/CUTIE cohort was 12 months. First DMSA was performed at median of 8.2 weeks (IQR 5-11.8 weeks) after the index UTI. In the simulated cohort, slightly higher yet statistically significantly rUTI was associated with top-down compared with bottom-up approach (24.4 vs 18.0%, p=0.045). On the other hand, the bottom-up resulted in more VCUG (100 vs 2.4%, p <0.001). Top-down resulted in fewer CAP-exposed patients (25 vs 0.4%, p <0.001) and lower overall CAP exposure (5 vs 162 days/person, p <0.001). Sensitivity analysis was performed with 40% VUR prevalence with similar results.Top-down approach was associated with slightly higher recurrent UTI. Compared to bottom-up approach, it significantly reduced the need of VCUG and CAP.

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Authors: Hsin-Hsiao Scott Wang, Dylan Cahill, John Panagides, Tanya Logvinenko, Caleb Nelson