Technical Report: Urinary Tract Infections in Febrile Infants and Young Children

Downs, Stephen M.

doi:10.1542/peds.103.4.e54

Cited by 212 publications

(117 citation statements)

References 155 publications

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“…This model was found to have an AUROC of 0.80 (95% CI 0.78 to 0.82). Data from six primary studies of dipstick testing in children aged < 5 years 70,[138][139][140][141][142] suggest that a dipstick positive for both nitrite and leucocyte may be useful for ruling in a diagnosis of UTI, while dipstick negative for both nitrite and leucocyte may be useful for ruling it out. However, these data were heterogeneous and should be interpreted with caution.…”

Section: 135mentioning

confidence: 99%

“…103 While the unit costs of laboratory testing and antibiotic prescribing are relatively low, 56 the economic implications of new clinical algorithms for urine sampling and testing may be substantial owing to (1) the large numbers of children who present with non-specific symptoms which might be caused by UTI; (2) the cost of subsequent diagnostic tests used to further evaluate children with recurrent/atypical UTI; 2 (3) the substantial costs and impact on quality of life of a missed diagnosis that leads to rare but serious complications of UTI; and (4) the wider, long-term population impact of diagnostic algorithms on antibiotic prescribing and bacterial resistance. 104 The few economic evaluations of the diagnosis of UTI in young children 56,142,143 have primarily aimed to identify the most cost-effective test or series of tests for diagnosing UTI rather than address the important issue of which children should be selected for testing in the first place. There is limited evidence on which children should have a urine sample taken and by what sampling method, and which urinalysis tests should be used to guide initial treatment.…”

Section: Introductionmentioning

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%

Section: Introductionmentioning

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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“…The main cause for thoroughly investigating and treating the fi rst UTI is to detect or roll out the presence of any renal or urinary tract abnormality that may be correctable, or predispose to repeated infections and long term renal damage. Based on the review carried out by the American Academy of Pediatrics VUR is the most commonly detected abnormality with a prevalence of 7% to 85% in children with UTI [5][6][7].…”

Section: Amongst Bacterial Infections Urinary Tract Infection (Uti)mentioning

confidence: 99%

“…However, for 60% to 80% of the children, voiding cystourethrography is a posteriori normal [1,5,[10][11][12][13]. Besides, it has disadvantages, including exposure to high dosage of radiation, a risk of iatrogenic UTI, and pain [6,[14][15][16].…”

Section: Amongst Bacterial Infections Urinary Tract Infection (Uti)mentioning

confidence: 99%

Serum Procalcitonin Level is a Useful Predictor of Dilating Vesicoureteral Reflux in Patients with First Febrile Urinary Tract Infection

Shalaby¹,

Elsayed²

2017

Arch Clin Nephrol

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Background: Procalcitonin (PCT) has been proposed as a novel biomarker for prediction of Vesicoureteral Refl ux (VUR). Since VUR is the most important risk factor for occurrence of pyelonephritis and renal tissue infl ammation, serum PCT level may have a relationship with VUR. However, literature about the relationship between procalcitonin level and VUR is scanty. Aim:We evaluated the predictive value of serum PCT level in the diagnosis of VUR in children admitted with their fi rst febrile UTI. Methods:We investigated 140 children with the fi rst febrile UTI (2m-10 yrs.). Serum PCT was measured before initiation of antibiotics. Standard voiding cystourethrography (VCUG) was performed in all children as the gold standard for detection of VUR. Sensitivity and specifi city of a high PCT level was evaluated using the receiver operating characteristic curve.Results: Seventy three patients(52%) had no VUR, while 67patients (48%) had VUR at least in one kidney, including grade 1 to 2 in 20 patients (14.3%) and , grade 3-5 in 47 (34.7%). PCT level ranged from 0.45 ng/ml to 12.7 ng/ml and, was signifi cantly higher with increasing the grading of VUR. Comparing procalcitonin levels with VCUG results, a sensitivity of 94% and a specifi city of 72% was obtained at a procalcitonin level of 0.52 ng/ml for diagnosis dilating VUR. There was a signifi cant correlation between PCT level and C-reactive protein. Conclusion:This study described that the PCT as an infl ammatory marker with proper sensitivity, specifi city, PPV and NPV seems likely benefi cial to predict dilating VUR.

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“…1 Since UTIs can lead to permanent kidney damage, it is relevant to identify and provide treatment for predisposing factors in order to reduce their frequency and, as a result, the associated morbidity. 2 These include anatomo-functional factors, such as vesicoureteral reflux (VUR) and bladder dysfunction, and metabolic factors, mainly idiopathic hypercalciuria (IH).…”

Section: Introductionmentioning

confidence: 99%

Idiopathic hypercalciuria in children with urinary tract infection

2014

Arch Argent Pediat

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Introduction. Idiopathic hypercalciuria (IH)predisposes to urinary tract infections (UTIs); however, there is scarce local information regarding such association. Our objectives were to estimate IH prevalence in children with UTI and to assess whether there were differences in relation to the presence or absence of vesicoureteral reflux (VUR). Additionally, the association between IH and salt intake was studied. Population and Methods. Calciuria was determined in patients younger than 18 years old on whom UTI had been studied (ultrasound and voiding cystourethrogram), and who had no secondary causes of hypercalciuria. IH was defined as a calcium to creatinine ratio of >0.8, 0.6, 0.5 and 0.2 in children aged 0 to 6 months old, 7 to12 months old, 12 to 24 months old and older than 2 years old, respectively; and a high sodium intake with a urinary sodium to potassium ratio of ≥2.5. Results. IH prevalence among 136 patients (87 girls, median age: 3 years old) was 20%. Patients with VUR (n= 54) and without VUR (n= 82) had similar characteristics in terms of sex, weight, height, age at diagnosis and age at the time of the study, and clinical features (hematuria, nephrolithiasis, colicky pain, and recurrent UTI), family history of kidney stone formation, and IH prevalence (26% versus 16%, p= 0.24). A high sodium intake was more frequently observed in children with hypercalciuria than in those with normal urine calcium levels (76% versus 46%, p= 0.007). Conclusions. IH prevalence in children with UTI was high (20%), with no differences observed between patients with and without VUR. As a recommendation, the presence of IH should be detected in children with UTI, regardless of VUR presence or absence.

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Technical Report: Urinary Tract Infections in Febrile Infants and Young Children

Cited by 212 publications

References 155 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

Serum Procalcitonin Level is a Useful Predictor of Dilating Vesicoureteral Reflux in Patients with First Febrile Urinary Tract Infection

Idiopathic hypercalciuria in children with urinary tract infection

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