Diagnosis of urinary tract infection in childhood based on examination of pared non-catheter and catheter specimens of urine.

Braude, Hillel D.; Forfar, J. O.; Gould, J. C.; McLeod, J. W.

doi:10.1136/bmj.4.5581.702

Cited by 19 publications

(15 citation statements)

References 3 publications

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“…62 Combined with the studies identified by our previous reviews 56,116 this gives a total of six included studies for urine sampling, five primary studies and one systematic review for clinical signs and symptoms, and eight primary studies and one systematic review for dipstick testing (Figure 34). We identified a total of six studies that assessed urine sampling methods: four from the HTA review, [57][58][59][60] one from the BMJ paper 61 and one from our update searches. 62 …”

Section: Resultsmentioning

confidence: 99%

“…Two studies compared culture results from urine samples obtained by bag specimens with those obtained by catheter. 58,61 The appropriateness of a catheter specimen as the reference standard is questionable, meaning that these results are of limited value. One study compared culture of a nappy pad specimen with culture of SPA samples.…”

Section: Methods Of Urine Sampling In Primary Carementioning

confidence: 99%

“…[57][58][59][60][61][62] Two studies compared culture of urine bag specimens with culture of SPA samples. 57,59 One reported a sensitivity of 100% and the other of 50%; both studies found specificity to be around 90%.…”

Section: Methods Of Urine Sampling In Primary Carementioning

confidence: 99%

“…Two studies compared culture results from urine samples obtained by bag specimens with those obtained by catheter. 58,61 One reported sensitivity of 81% and specificity of 87%;…”

Section: Bag Specimensmentioning

confidence: 99%

“…2 We have updated the 2006 systematic review for the DUTY study, which assessed the accuracy of dipstick testing for UTI in children (see Appendix 2). We found data from six primary studies [57][58][59][60][61][62] (including those included in the HTA review) which assessed dipstick testing for LE and nitrite in children aged < 5 years. There was substantial heterogeneity across studies.…”

Section: Dipstick Testsmentioning

confidence: 99%

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The Diagnosis of Urinary Tract infection in Young children (DUTY): a diagnostic prospective observational study to derive and validate a clinical algorithm for the diagnosis of urinary tract infection in children presenting to primary care with an acute illness

Hay

Birnie²,

Busby³

et al. 2016

Health Technol Assess

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BackgroundIt is not clear which young children presenting acutely unwell to primary care should be investigated for urinary tract infection (UTI) and whether or not dipstick testing should be used to inform antibiotic treatment.ObjectivesTo develop algorithms to accurately identify pre-school children in whom urine should be obtained; assess whether or not dipstick urinalysis provides additional diagnostic information; and model algorithm cost-effectiveness.DesignMulticentre, prospective diagnostic cohort study.Setting and participantsChildren < 5 years old presenting to primary care with an acute illness and/or new urinary symptoms.MethodsOne hundred and seven clinical characteristics (index tests) were recorded from the child’s past medical history, symptoms, physical examination signs and urine dipstick test. Prior to dipstick results clinician opinion of UTI likelihood (‘clinical diagnosis’) and urine sampling and treatment intentions (‘clinical judgement’) were recorded. All index tests were measured blind to the reference standard, defined as a pure or predominant uropathogen cultured at ≥ 105colony-forming units (CFU)/ml in a single research laboratory. Urine was collected by clean catch (preferred) or nappy pad. Index tests were sequentially evaluated in two groups, stratified by urine collection method: parent-reported symptoms with clinician-reported signs, and urine dipstick results. Diagnostic accuracy was quantified using area under receiver operating characteristic curve (AUROC) with 95% confidence interval (CI) and bootstrap-validated AUROC, and compared with the ‘clinician diagnosis’ AUROC. Decision-analytic models were used to identify optimal urine sampling strategy compared with ‘clinical judgement’.ResultsA total of 7163 children were recruited, of whom 50% were female and 49% were < 2 years old. Culture results were available for 5017 (70%); 2740 children provided clean-catch samples, 94% of whom were ≥ 2 years old, with 2.2% meeting the UTI definition. Among these, ‘clinical diagnosis’ correctly identified 46.6% of positive cultures, with 94.7% specificity and an AUROC of 0.77 (95% CI 0.71 to 0.83). Four symptoms, three signs and three dipstick results were independently associated with UTI with an AUROC (95% CI; bootstrap-validated AUROC) of 0.89 (0.85 to 0.95; validated 0.88) for symptoms and signs, increasing to 0.93 (0.90 to 0.97; validated 0.90) with dipstick results. Nappy pad samples were provided from the other 2277 children, of whom 82% were < 2 years old and 1.3% met the UTI definition. ‘Clinical diagnosis’ correctly identified 13.3% positive cultures, with 98.5% specificity and an AUROC of 0.63 (95% CI 0.53 to 0.72). Four symptoms and two dipstick results were independently associated with UTI, with an AUROC of 0.81 (0.72 to 0.90; validated 0.78) for symptoms, increasing to 0.87 (0.80 to 0.94; validated 0.82) with the dipstick findings. A high specificity threshold for the clean-catch model was more accurate and less costly than, and as effective as, clinical judgement. The additional diagnostic utility of dipstick testing was offset by its costs. The cost-effectiveness of the nappy pad model was not clear-cut.ConclusionsClinicians should prioritise the use of clean-catch sampling as symptoms and signs can cost-effectively improve the identification of UTI in young children where clean catch is possible. Dipstick testing can improve targeting of antibiotic treatment, but at a higher cost than waiting for a laboratory result. Future research is needed to distinguish pathogens from contaminants, assess the impact of the clean-catch algorithm on patient outcomes, and the cost-effectiveness of presumptive versus dipstick versus laboratory-guided antibiotic treatment.FundingThe National Institute for Health Research Health Technology Assessment programme.

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Section: Resultsmentioning

confidence: 99%

Section: Methods Of Urine Sampling In Primary Carementioning

confidence: 99%

Section: Methods Of Urine Sampling In Primary Carementioning

confidence: 99%

“…Two studies compared culture results from urine samples obtained by bag specimens with those obtained by catheter. 58,61 One reported sensitivity of 81% and specificity of 87%;…”

Section: Bag Specimensmentioning

confidence: 99%