Improving the Diagnosis and Treatment of Urinary Tract Infection in Young Children in Primary Care: Results from the DUTY Prospective Diagnostic Cohort Study

Abstract

PURPOSE Up to 50% of urinary tract infections (UTIs) in young children are missed in primary care. Urine culture is essential for diagnosis, but urine collection is often difficult. Our aim was to derive and internally validate a 2-step clinical rule using (1) symptoms and signs to select children for urine collection; and (2) symptoms, signs, and dipstick testing to guide antibiotic treatment. METHODSWe recruited acutely unwell children aged under 5 years from 233 primary care sites across England and Wales. Index tests were parent-reported symptoms, clinician-reported signs, urine dipstick results, and clinician opinion of UTI likelihood (clinical diagnosis before dipstick and culture). The reference standard was microbiologically confirmed UTI cultured from a clean-catch urine sample. We calculated sensitivity, specificity, and area under the receiver operator characteristic (AUROC) curve of coefficient-based (graded severity) and pointsbased (dichotomized) symptom/sign logistic regression models, and we then internally validated the AUROC using bootstrapping.RESULTS Three thousand thirty-six children provided urine samples, and culture results were available for 2,740 (90%). Of these results, 60 (2.2%) were positive: the clinical diagnosis was 46.6% sensitive, with an AUROC of 0.77. Previous UTI, increasing pain/crying on passing urine, increasingly smelly urine, absence of severe cough, increasing clinician impression of severe illness, abdominal tenderness on examination, and normal findings on ear examination were associated with UTI. The validated coefficient-and points-based model AUROCs were 0.87 and 0.86, respectively, increasing to 0.90 and 0.90, respectively, by adding dipstick nitrites, leukocytes, and blood.CONCLUSIONS A clinical rule based on symptoms and signs is superior to clinician diagnosis and performs well for identifying young children for noninvasive urine sampling. Dipstick results add further diagnostic value for empiric antibiotic treatment. Ann Fam Med 2016;14:325-336. doi: 10.1370/afm.1954. INTRODUCTIONT he accurate and timely diagnosis of urinary tract infection (UTI) in children is important to alleviate short-term suffering 1 and prevent the possible long-term consequences, such as renal scarring, impaired renal growth, recurrent pyelonephritis, impaired glomerular function, hypertension, end-stage renal disease, and preeclampsia. [2][3][4] Guidelines universally recommend microbiological confirmation using urine samples collected by clean catch (preferred in Europe), 5 catheterization, or suprapubic aspiration for unwell children where clean catch is not immediately available (preferred in the United States 6 and Australia 7 ). There are 3 possible explanations why one-half of UTIs are not diagnosed at the earliest opportunity in UK primary care. 8 First, relevant evidence in primary care regarding which children should be suspected of having a UTI is scarce. Guidelines, which emphasize the importance 326of fever, 6,7,9 are largely informed by studies conducted in emerg...

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

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