PURPOSE Accurate diagnosis of urinary tract infection in children is essential because children left untreated can experience permanent renal injury. We aimed to assess the diagnostic value of clinical features of pediatric urinary tract infection. METHODSWe performed a systematic review and meta-analysis of diagnostic test accuracy studies in ambulatory care. We searched the PubMed, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Health Technology Assessment, and Database of Abstracts of Reviews of Effects databases from inception to January 27, 2020 for studies reporting 2 × 2 diagnostic accuracy data for clinical features compared with urine culture in children aged <18 years. For each clinical feature, we calculated likelihood ratios and posttest probabilities of urinary tract infection. To estimate summary parameters, we conducted a bivariate random effects metaanalysis and hierarchical summary receiver operating characteristic analysis. RESULTSA total of 35 studies (N = 78,427 patients) of moderate to high quality were included, providing information on 58 clinical features and 6 prediction rules. Only circumcision (negative likelihood ratio [LR-] 0.24; 95% CI, 0.08-0.72; n = 8), stridor (LR-0.20; 95% CI, 0.05-0.81; n = 1), and diaper rash (LR-0.13; 95% CI, 0.02-0.92; n = 1) were useful for ruling out urinary tract infection. Body temperature or fever duration showed limited diagnostic value (area under the receiver operating characteristic curve 0.61; 95% CI, 0.47-0.73; n = 16). The Diagnosis of Urinary Tract Infection in Young Children score, Gorelick Scale score, and UTIcalc (https://uticalc.pitt.edu) might be useful to identify children eligible for urine sampling.CONCLUSIONS Few clinical signs and symptoms are useful for diagnosing or ruling out urinary tract infection in children. Clinical prediction rules might be more accurate; however, they should be validated externally. Physicians should not restrict urine sampling to children with unexplained fever or other features suggestive of urinary tract infection.

Background Accurate diagnosis of urinary tract infection is essential as children left untreated may suffer permanent renal injury. Aim To compare the diagnostic values of biomarkers or clinical prediction rules for urinary tract infections in children presenting to ambulatory care. Design and setting Systematic review and meta-analysis of ambulatory care studies. Methods Medline, Embase, WOS, CINAHL, Cochrane library, HTA and DARE were searched until 21 May 2021. We included diagnostic studies on urine or blood biomarkers for cystitis or pyelonephritis in children below 18 years of age. We calculated sensitivity, specificity and likelihood ratios. Data were pooled using a bivariate random effects model and a Hierarchical Summary Receiver Operating Characteristic analysis. Results Seventy-five moderate to high quality studies were included in this review and 54 articles in the meta-analyses. The area under the receiver-operating-characteristics curve to diagnose cystitis was 0.75 (95%CI 0.62 to 0.83, n = 9) for C-reactive protein, 0.71 (95% CI 0.62 to 0.80, n = 4) for procalcitonin, 0.93 (95% CI 0.91 to 0.96, n = 22) for the dipstick test (nitrite or leukocyte esterase ≥trace), 0.94 (95% CI 0.58 to 0.98, n = 9) for urine white blood cells and 0.98 (95% CI 0.92 to 0.99, n = 12) for Gram-stained bacteria. For pyelonephritis, C-reactive protein < 20 mg/l had LR- of 0.10 (95%CI 0.04–0.30) to 0.22 (95%CI 0.09–0.54) in children with signs suggestive of urinary tract infection. Conclusions Clinical prediction rules including the dipstick test biomarkers can support family physicians while awaiting urine culture results. CRP and PCT have low accuracy for cystitis, but might be useful for pyelonephritis.

Urinary tract infections (UTI), comprising cystitis and pyelonephritis, occur in 6% and 0.6% of acutely ill children presenting to primary care, respectively. 1,2 UTI diagnosis is important, as adequate and timely treatment can alleviate short-term distress of the child, prevent renal scarring 3 and progression to a more serious systemic infection. 4 Diagnosis is challenging, as only a minority of children with UTI present with typical UTI symptoms. In a previous study, we found that changes in urine appearance, such as cloudy urine, malodorous urine and haematuria, are alarming signs for UTI, while only few features (e.g., circumcision, stridor) lower the probability of UTI considerably. 5 Because the clinical presentation is often unclear, primary care physicians need appropriate collection methods for urine testing

Background: Diagnosis and management of childhood urinary tract infections (UTI) is challenging in general practice, because of a range of factors. Aim: To explore general practitioners’ perspectives concerning the barriers and facilitators for diagnosis and management of childhood UTI. Design and setting: Qualitative study in general practice, Belgium. Method: Semi-structured interviews with 23 general practitioners from January 2021 to June 2021. Interviews were video- and audio recorded, transcribed verbatim and analyzed using a thematic approach. Results: The barriers for early diagnosis of UTI were the assumption of low UTI prevalence and aspecific presentation of UTI in children, difficulties in urine collection, and diagnostic uncertainty. All GPs indicated they sampled urine in either children with specific UTI features (dysuria, abdominal pain), or unexplained fever. Facilitators for UTI screening were instructional material for parents, skill training for GPs, additional nursing staff, novel noninvasive convenient collection methods, online decision support informing parents when to bring a urine sample to the consultation and an accurate easy-to-use point-of-care test for UTI. Empirical antibiotic treatment was initiated based on dipstick test results, clinical features suggestive of UTI, severity of illness, gut feeling, long duration of fever, time of the day and parents’ ability to judge disease severity. Conclusion: The assumption of a low UTI prevalence, absence of obvious UTI features and difficult urine sampling might cause childhood UTIs to go undetected in general practice. Diagnostic uncertainty makes appropriate treatment challenging.

Background To improve the management of childhood urinary tract infections, it is essential to understand the incidence rates, testing and treatment strategy. Methods A retrospective study using data from 45 to 104 general practices (2000 to 2020) in Flanders (Belgium). We calculated the incidence rates (per 1000 person-years) of cystitis, pyelonephritis, and lab-based urine tests per age (< 2, 2-4, 5-9 and 10-18 years)) and gender in children and performed an autoregressive time-series analysis and seasonality analysis. In children with UTI, we calculated the number of lab-based urine tests and antibiotic prescriptions per person-year and performed an autoregressive time-series analysis. Results There was a statistically significant increase in the number of UTI episodes from 2000 to 2020 in each age group (p < 0.05), except in boys 2-4 years. Overall, the change in incidence rate was low. In 2020, the incidence rates of cystitis were highest in girls 2-4 years old (40.3 /1000 person-years 95%CI 34.5-46.7) and lowest in boys 10-18 (2.6 /1000 person-years 95%CI 1.8-3.6) The incidence rates of pyelonephritis were highest in girls 2-4 years (5.5, 95%CI 3.5-8.1 /1000 person-years) and children < 2 years of age (boys: 5.4, 95%CI 3.1-8.8 and girls: 4.9, 95%CI 2.7-8.8 /1000 person-years). In children 2-10 years, there was an increase in number of lab-based urine tests per cystitis episode per year and a decrease in total number of electronic antibiotic prescriptions per cystitis episode per year, from 2000 to 2020. In children with cystitis < 10 years in 2020, 51% (95%CI 47-56%) received an electronic antibiotic prescription, of which the majority were broad-spectrum agents. Conclusions Over the last 21 years, there was a slight increase in the number of UTI episodes diagnosed in children in Flemish general practices, although the overall change was low. More targeted antibiotic therapy for cystitis in accordance with clinical guidelines is necessary to reduce the use of broad-spectrum agents in children below 10 years.