Urinary tract infection in infants with unexplained fever: A collaborative study

Roberts, Kenneth B.; Charney, Evan; Sweren, Ronald J.; Ahonkhai, Vincent I.; Bergman, David A.; Coulter, Molly P.; Fendrick, Gerald M.; Lachman, Barry S.; Lawless, Michael R.; Pantell, Robert H.; Stein, Martin T.

doi:10.1016/s0022-3476(83)80702-1

Cited by 112 publications

(57 citation statements)

References 12 publications

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“…[19][20][21][22][23][24] The presence of another, clinically obvious source of infection reduces the likelihood of UTI by one-half. 25 In a survey asking, "What yield is required to warrant urine culture in febrile infants?," the threshold was less than 1% for 10.4% of academicians and 11.7% for practitioners 26 ; when the threshold was increased to 1% to 3%, 67.5% of academicians and 45.7% of practitioners considered the yield sufficiently high to warrant urine culture. Therefore, attempting to operationalize "low likelihood" (ie, below a threshold that warrants a urine culture) does not produce an absolute percentage; clinicians will choose a threshold depending on factors such as their confidence that contact will be maintained through the illness (so that a specimen can be obtained at a later time) and comfort with diagnostic uncertainty.…”

Section: Action Statement 2bmentioning

confidence: 93%

Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months

Roberts¹

2011

Pediatrics

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OBJECTIVE: To revise the American Academy of Pediatrics practice parameter regarding the diagnosis and management of initial urinary tract infections (UTIs) in febrile infants and young children. METHODS:Analysis of the medical literature published since the last version of the guideline was supplemented by analysis of data provided by authors of recent publications. The strength of evidence supporting each recommendation and the strength of the recommendation were assessed and graded.

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Section: Action Statement 2bmentioning

confidence: 93%

Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months

Roberts¹

2011

Pediatrics

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634

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“…2 Others have also advocated urine 'screening' in some groups of children, for example in all febrile infants or broader urine sampling strategies in ill children. 70,73,74 A survey of 200 paediatricians in 1983 concerning the management of febrile infants found that all of the respondents felt that a UTI prevalence of 5% would warrant urine sampling in all; more than 80% felt that a prevalence of more than 3% would warrant urine sampling in all, and about half felt that a prevalence of between 1% and 3% would warrant sampling urine from all febrile children. A recent retrospective study concluded that urine analysis should be added to the NICE 'traffic light' system for the detection of serious illness in febrile children < 5 years old.…”

Section: Summary Of Symptoms and Signsmentioning

confidence: 99%

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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“…However, the findings of a positive urine culture in a patient with a negative UA also may reflect a false-positive urine culture due to asymptomatic bacteriuria or contamination. [7][8][9][10] The 2011 American Academy of Pediatrics' (AAP) UTI guideline suggests that the diagnosis of UTI should require an abnormal UA in addition to a positive urine culture. 4 However, these guidelines do not include infants ,2 months, and young infants with a negative UA and a positive urine culture are generally considered to have UTI.…”

Section: What This Study Addsmentioning

confidence: 99%

Diagnostic Accuracy of the Urinalysis for Urinary Tract Infection in Infants <3 Months of Age

et al. 2015

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Urinary tract infection in infants with unexplained fever: A collaborative study

Cited by 112 publications

References 12 publications

Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months

Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months

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

Diagnostic Accuracy of the Urinalysis for Urinary Tract Infection in Infants <3 Months of Age

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Urinary tract infection in infants with unexplained fever: A collaborative study

Cited by 112 publications

References 12 publications

Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months

Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months

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

Diagnostic Accuracy of the Urinalysis for Urinary Tract Infection in Infants &lt;3 Months of Age

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Diagnostic Accuracy of the Urinalysis for Urinary Tract Infection in Infants <3 Months of Age