Clinical and laboratory characteristics of non-E coli urinary tract infections

Friedman, S; Reif, Shimon; Assia, Ayala; Levy, Isaac

doi:10.1136/adc.2005.080721

Cited by 47 publications

(38 citation statements)

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“…Our definition of UTI excluded atypical bacteria causing UTIs, which are also thought to be more common in younger children. 137,138 We are aware of four primary studies 1,65-67 of 18,796 children and one systematic review of eight primary studies 3 in children aged < 5 years (7892 children) that assessed the diagnostic value of clinical symptoms and signs. The only other primary care study found younger age and urinary frequency and dysuria to be independently associated with UTI.…”

Section: 135mentioning

confidence: 99%

“…Our definition of UTI excluded atypical bacteria which are also thought to be more common in younger children. 137,138 There is some evidence that false-positive samples taken from children can be identified by taking sequential urine samples. 81 We considered, however, that the increased burden on patients and the health services associated with taking two separate samples from each child would lead to fewer children being sampled.…”

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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: 135mentioning

confidence: 99%

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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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“…1 UTI is the term applied to all conditions, irrespective of localization of infection, characterized by invasion of urinary tract with pathogens and associated with the presence of significant bacteriuria. Significant bacteriuria means colony count >10 5 colony forming units (CFU)/ml of single species on clean catch specimen and >50,000 CFU/ml in transurethral specimens. 2 Adequate treatment of acute UTI depends on knowledge of the local pattern of causative pathogens, their antimicrobial resistance and the associated underlying risk factors.…”

Section: Introductionmentioning

confidence: 99%

Antibiotic sensitivity pattern of pathogens in children with urinary tract infection in a tertiary care hospital in Kachchh, Gujarat, India

Thaddanee

Khilnani

Shah

et al. 2017

Int J Contemp Pediatr

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Background: This prospective observational study was conducted in a tertiary care hospital in Kachchh, over a period of 6 months, to know the antibiotic sensitivity pattern of pathogens in children less than 18 years old with Urinary Tract Infection (UTI). Methods: Between December 2016 to June 2017, 186 children met the inclusion criterion. Urine samples were collected and processed for urine routine microscopy, culture and antibiotic sensitivity as per the standard laboratory guidelines. Urine culture was positive in 50 cases, which were further evaluated to find out any renal disease. All patients were given 10-14 days antibiotics course and follow-up urine reports were done. Patients were considered cured when the follow-up urine reports were normal. Results: E. coli was the commonest organism (34%) isolated, found mainly in 1-5 years age group (20%). Enterococci were isolated in 32% cases, most of which were less than 5 years of age (28%). Klebsiella (12%), Methicillin Resistant Staphylococcus Aureus (MRSA) (10%), Coagulase negative staphylococci (6%), Pseudomonas (2%) and Budding yeast cell (4%) were the less frequent organisms isolated. E. coli were found to be less sensitive to different Aminoglycosides (11.7% -23.5%), Cephalosporins (11.7% -52.9%), Fluoroquinolones (5.8% -11.7%), Cotrimoxazole (17.6%) and Piperacillin (17.6%), but were more sensitive (70.6%) to Imipenems. Enterococci were also partially sensitive to Aminoglycosides (6.2-18.7%), Cephalosporins (25-37.5.7%), Fluoroquinolones (6.25-12.5%), Penicillin-G (50%), Piperacillin (31.25%) and Co-trimoxazole (43.75%), but had good sensitivity for Imipenems (68.7%), Linezolid (75%) and Vancomycin (81.2%). Similarly, MRSA was 100% sensitive to Linezolid and Imipenem but partially sensitive (20-60%) to other antibiotics. Klebsiella showed 16.65-33.3% sensitivity to all antibiotics except Imipenem (83.3%) and was 100% resistant to Co-trimoxazole. Coagulase negative Staphylococci (CONS) remained 100% sensitive to all antibiotics and Pseudomonas was resistant to all antibiotics. Conclusions: The study concludes that pathogens for UTI in children have developed resistance, even to the newer generation antibiotics, probably due to the irrational use of antibiotics. In view of emergence of multi drug resistant pathogens, which carry considerable morbidity and mortality, every effort must be taken to use antibiotics judiciously.

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“…The conservative criteria for a microbiological UTI diagnosis may have also contributed. This study reference standard defined 'uropathogens' as members of the Enterobacteriaceae family at the UK guidelines' 19,20 threshold of a pure/ predominant growth of ≥10 5 CFU/mL. It was decided not to use a lower threshold, as this carries an increased risk of false-positives, although there are recommendations that a lower threshold should be used.…”

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Nappy pad urine samples for investigation and treatment of UTI in young children: the ‘DUTY’ prospective diagnostic cohort study

et al. 2016

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Acutely unwell children <5 years presenting to 233 UK primary care sites. MethodLogistic regression to identify independent associations of symptoms, signs, and urine dipstick test results with UTI; diagnostic utility quantified as area under the receiver operator curves (AUROC). Nappy pad rule characteristics, AUROC, and contamination, compared with findings from clean-catch samples. ResultsNappy pad samples were obtained from 3205 children (82% aged <2 years; 48% female), culture results were available for 2277 (71.0%) and 30 (1.3%) had a UTI on culture. Female sex, smelly urine, darker urine, and the absence of nappy rash were independently associated with a UTI, with an internally-validated, coefficient model AUROC of 0.81 (0.87 for clean-catch), which increased to 0.87 (0.90 for clean-catch) with the addition of dipstick results. GPs' 'working diagnosis' had an AUROC 0.63 (95% confidence intervals [CI] = 0.53 to 0.72). A total of 12.2% of nappy pad and 1.8% of cleancatch samples were 'frankly contaminated' (risk ratio 6.66; 95% CI = 4.95 to 8.96; P<0.001). ConclusionNappy pad urine culture results, with features that can be reported by parents and dipstick tests, can be clinically useful, but are less accurate and more often contaminated compared with clean-catch urine culture.

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Clinical and laboratory characteristics of non-E coli urinary tract infections

Cited by 47 publications

References 8 publications

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

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

Antibiotic sensitivity pattern of pathogens in children with urinary tract infection in a tertiary care hospital in Kachchh, Gujarat, India

Nappy pad urine samples for investigation and treatment of UTI in young children: the ‘DUTY’ prospective diagnostic cohort study

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