Urinary Tract Infection–Child

Variant: 1 Child assigned male at birth (AMB). Younger than 2 months of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
US kidneys and bladder	Usually Appropriate	O
Voiding urosonography	May Be Appropriate (Disagreement)	O
Fluoroscopy voiding cystourethrography	May Be Appropriate (Disagreement)	☢☢
MRI abdomen and pelvis with IV contrast	Usually Not Appropriate	O
MRI abdomen and pelvis without IV contrast	Usually Not Appropriate	O
MRU without and with IV contrast	Usually Not Appropriate	O
Nuclear medicine cystography	Usually Not Appropriate	☢☢
CT abdomen and pelvis with IV contrast	Usually Not Appropriate	☢☢☢☢
CT abdomen and pelvis without IV contrast	Usually Not Appropriate	☢☢☢☢
DMSA renal scan	Usually Not Appropriate	☢☢☢
CT abdomen and pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢☢
CTU without and with IV contrast	Usually Not Appropriate	☢☢☢☢☢

Variant: 2 Child assigned female at birth (AFAB). Younger than 2 months of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
US kidneys and bladder	Usually Appropriate	O
Voiding urosonography	May Be Appropriate	O
Fluoroscopy voiding cystourethrography	May Be Appropriate	☢☢
Nuclear medicine cystography	May Be Appropriate	☢☢
MRI abdomen and pelvis with IV contrast	Usually Not Appropriate	O
MRI abdomen and pelvis without IV contrast	Usually Not Appropriate	O
MRU without and with IV contrast	Usually Not Appropriate	O
CT abdomen and pelvis with IV contrast	Usually Not Appropriate	☢☢☢☢
CT abdomen and pelvis without IV contrast	Usually Not Appropriate	☢☢☢☢
DMSA renal scan	Usually Not Appropriate	☢☢☢
CT abdomen and pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢☢
CTU without and with IV contrast	Usually Not Appropriate	☢☢☢☢☢

Variant: 3 Child. 2 months to 6 years of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
US kidneys and bladder	Usually Appropriate	O
Voiding urosonography	May Be Appropriate (Disagreement)	O
Fluoroscopy voiding cystourethrography	May Be Appropriate	☢☢
Nuclear medicine cystography	May Be Appropriate	☢☢
MRI abdomen and pelvis with IV contrast	Usually Not Appropriate	O
MRI abdomen and pelvis without IV contrast	Usually Not Appropriate	O
MRU without and with IV contrast	Usually Not Appropriate	O
CT abdomen and pelvis with IV contrast	Usually Not Appropriate	☢☢☢☢
CT abdomen and pelvis without IV contrast	Usually Not Appropriate	☢☢☢☢
DMSA renal scan	Usually Not Appropriate	☢☢☢
CT abdomen and pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢☢
CTU without and with IV contrast	Usually Not Appropriate	☢☢☢☢☢

Variant: 4 Child. Older than 6 years of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
US kidneys and bladder	May Be Appropriate (Disagreement)	O
Voiding urosonography	May Be Appropriate (Disagreement)	O
Fluoroscopy voiding cystourethrography	Usually Not Appropriate	☢☢
MRI abdomen and pelvis with IV contrast	Usually Not Appropriate	O
MRI abdomen and pelvis without IV contrast	Usually Not Appropriate	O
MRU without and with IV contrast	Usually Not Appropriate	O
Nuclear medicine cystography	Usually Not Appropriate	☢☢
CT abdomen and pelvis with IV contrast	Usually Not Appropriate	☢☢☢☢
CT abdomen and pelvis without IV contrast	Usually Not Appropriate	☢☢☢☢
DMSA renal scan	Usually Not Appropriate	☢☢☢
CT abdomen and pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢☢
CTU without and with IV contrast	Usually Not Appropriate	☢☢☢☢☢

Variant: 5 Child. Atypical or recurrent febrile urinary tract infections. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
US kidneys and bladder	Usually Appropriate	O
Voiding urosonography	Usually Appropriate	O
Fluoroscopy voiding cystourethrography	Usually Appropriate	☢☢
Nuclear medicine cystography	May Be Appropriate	☢☢
CT abdomen and pelvis with IV contrast	May Be Appropriate	☢☢☢☢
DMSA renal scan	May Be Appropriate (Disagreement)	☢☢☢
MRI abdomen and pelvis with IV contrast	Usually Not Appropriate	O
MRI abdomen and pelvis without IV contrast	Usually Not Appropriate	O
MRU without and with IV contrast	Usually Not Appropriate	O
CT abdomen and pelvis without IV contrast	Usually Not Appropriate	☢☢☢☢
CT abdomen and pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢☢
CTU without and with IV contrast	Usually Not Appropriate	☢☢☢☢☢

Variant: 6 Child. Established vesicoureteral reflux. Follow-up imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
US kidneys and bladder	Usually Appropriate	O
Voiding urosonography	Usually Appropriate	O
Fluoroscopy voiding cystourethrography	Usually Appropriate	☢☢
Nuclear medicine cystography	Usually Appropriate	☢☢
MRU without and with IV contrast	May Be Appropriate (Disagreement)	O
DMSA renal scan	May Be Appropriate	☢☢☢
MRI abdomen and pelvis with IV contrast	Usually Not Appropriate	O
MRI abdomen and pelvis without IV contrast	Usually Not Appropriate	O
CT abdomen and pelvis with IV contrast	Usually Not Appropriate	☢☢☢☢
CT abdomen and pelvis without IV contrast	Usually Not Appropriate	☢☢☢☢
CT abdomen and pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢☢
CTU without and with IV contrast	Usually Not Appropriate	☢☢☢☢☢

Panel Members

Tushar Chandra, MD, MBBS^a; Manish Bajaj, MD^b; Ramesh S. Iyer, MD, MBA^c; Sherwin S. Chan, MD, PhD^d; Dianna M. E. Bardo, MD^e; Jimmy Chen, MD^f; Matthew L. Cooper, MD^g; Summer L. Kaplan, MD, MS^h; Terry L. Levin, MDⁱ; Michael M. Moore, MD^j; Craig A. Peters, MD^k; Mohsen Saidinejad, MD, MBA^l; Gary R. Schooler, MD^m; Narendra S. Shet, MDⁿ; Judy H. Squires, MD^o; Andrew T. Trout, MD^p; Sumit Pruthi, MD, MBBS^q.

Summary of Literature Review

Introduction/Background

Special Imaging Considerations

Initial Imaging Definition

Initial imaging is defined as imaging at the beginning of the care episode for the medical condition defined by the variant. More than one procedure can be considered usually appropriate in the initial imaging evaluation when:

There are procedures that are equivalent alternatives (i.e., only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care)

There are complementary procedures (i.e., more than one procedure is ordered as a set or simultaneously wherein each procedure provides unique clinical information to effectively manage the patient’s care).

Variant 1: Child assigned male at birth (AMAB). Younger than 2 months of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.

Variant 1: Child assigned male at birth (AMAB). Younger than 2 months of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.
A. CT abdomen and pelvis with IV contrast

Variant 2: Child assigned female at birth (AFAB). Younger than 2 months of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.

Variant 2: Child assigned female at birth (AFAB). Younger than 2 months of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.
A. CT abdomen and pelvis with IV contrast

Variant 3: Child. 2 months to 6 years of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.

Variant 3: Child. 2 months to 6 years of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.
A. CT abdomen and pelvis with IV contrast

Variant 3: Child. 2 months to 6 years of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.
B. CT abdomen and pelvis without and with IV contrast

Variant 3: Child. 2 months to 6 years of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.
C. CT abdomen and pelvis without IV contrast

Variant 3: Child. 2 months to 6 years of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.
D. CTU without and with IV contrast

Variant 3: Child. 2 months to 6 years of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.
E. DMSA renal scan

Variant 3: Child. 2 months to 6 years of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.
F. Fluoroscopy voiding cystourethrography

Variant 3: Child. 2 months to 6 years of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.
G. MRI abdomen and pelvis with IV contrast

Variant 3: Child. 2 months to 6 years of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.
H. MRI abdomen and pelvis without IV contrast

Variant 3: Child. 2 months to 6 years of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.
I. MRU without and with IV contrast

Variant 3: Child. 2 months to 6 years of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.
J. Nuclear medicine cystography

Variant 3: Child. 2 months to 6 years of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.
K. US kidneys and bladder

Variant 3: Child. 2 months to 6 years of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.
L. Voiding urosonography

Variant 4: Child. Older than 6 years of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.

Variant 4: Child. Older than 6 years of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.
A. CT abdomen and pelvis with IV contrast

Variant 4: Child. Older than 6 years of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.
B. CT abdomen and pelvis without and with IV contrast

Variant 4: Child. Older than 6 years of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.
C. CT abdomen and pelvis without IV contrast

Variant 4: Child. Older than 6 years of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.
D. CTU without and with IV contrast

Variant 4: Child. Older than 6 years of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.
E. DMSA renal scan

Variant 4: Child. Older than 6 years of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.
F. Fluoroscopy voiding cystourethrography

Variant 4: Child. Older than 6 years of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.
G. MRI abdomen and pelvis with IV contrast

Variant 4: Child. Older than 6 years of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.
H. MRI abdomen and pelvis without IV contrast

Variant 4: Child. Older than 6 years of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.
I. MRU without and with IV contrast

Variant 4: Child. Older than 6 years of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.
J. Nuclear medicine cystography

Variant 4: Child. Older than 6 years of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.
K. US kidneys and bladder

Variant 4: Child. Older than 6 years of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.
L. Voiding urosonography

Variant 5: Child. Atypical or recurrent febrile urinary tract infections. Initial imaging.

Variant 5: Child. Atypical or recurrent febrile urinary tract infections. Initial imaging.
A. CT abdomen and pelvis with IV contrast

Variant 5: Child. Atypical or recurrent febrile urinary tract infections. Initial imaging.
B. CT abdomen and pelvis without and with IV contrast

Variant 5: Child. Atypical or recurrent febrile urinary tract infections. Initial imaging.
C. CT abdomen and pelvis without IV contrast

Variant 5: Child. Atypical or recurrent febrile urinary tract infections. Initial imaging.
D. CTU without and with IV contrast

Variant 5: Child. Atypical or recurrent febrile urinary tract infections. Initial imaging.
E. DMSA renal scan

Variant 5: Child. Atypical or recurrent febrile urinary tract infections. Initial imaging.
F. Fluoroscopy voiding cystourethrography

Variant 5: Child. Atypical or recurrent febrile urinary tract infections. Initial imaging.
G. MRI abdomen and pelvis with IV contrast

Variant 5: Child. Atypical or recurrent febrile urinary tract infections. Initial imaging.
H. MRI abdomen and pelvis without IV contrast

Variant 5: Child. Atypical or recurrent febrile urinary tract infections. Initial imaging.
I. MRU without and with IV contrast

Variant 5: Child. Atypical or recurrent febrile urinary tract infections. Initial imaging.
J. Nuclear medicine cystography

Variant 5: Child. Atypical or recurrent febrile urinary tract infections. Initial imaging.
K. US kidneys and bladder

Variant 5: Child. Atypical or recurrent febrile urinary tract infections. Initial imaging.
L. Voiding urosonography

Variant 6: Child. Established vesicoureteral reflux. Follow-up imaging.

Variant 6: Child. Established vesicoureteral reflux. Follow-up imaging.
A. CT abdomen and pelvis with IV contrast

Variant 6: Child. Established vesicoureteral reflux. Follow-up imaging.
B. CT abdomen and pelvis without and with IV contrast

Variant 6: Child. Established vesicoureteral reflux. Follow-up imaging.
C. CT abdomen and pelvis without IV contrast

Variant 6: Child. Established vesicoureteral reflux. Follow-up imaging.
D. CTU without and with IV contrast

Variant 6: Child. Established vesicoureteral reflux. Follow-up imaging.
E. DMSA renal scan

Variant 6: Child. Established vesicoureteral reflux. Follow-up imaging.
F. Fluoroscopy voiding cystourethrography

Variant 6: Child. Established vesicoureteral reflux. Follow-up imaging.
G. MRI abdomen and pelvis with IV contrast

Variant 6: Child. Established vesicoureteral reflux. Follow-up imaging.
H. MRI abdomen and pelvis without IV contrast

Variant 6: Child. Established vesicoureteral reflux. Follow-up imaging.
I. MRU without and with IV contrast

Variant 6: Child. Established vesicoureteral reflux. Follow-up imaging.
J. Nuclear medicine cystography

Variant 6: Child. Established vesicoureteral reflux. Follow-up imaging.
K. US kidneys and bladder

Variant 6: Child. Established vesicoureteral reflux. Follow-up imaging.
L. Voiding urosonography

Summary of Highlights

Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria^® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations
Relative Radiation Level*	Adult Effective Dose Estimate Range	Pediatric Effective Dose Estimate Range
O	0 mSv	0 mSv
☢	<0.1 mSv	<0.03 mSv
☢☢	0.1-1 mSv	0.03-0.3 mSv
☢☢☢	1-10 mSv	0.3-3 mSv
☢☢☢☢	10-30 mSv	3-10 mSv
☢☢☢☢☢	30-100 mSv	10-30 mSv
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”

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Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.