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The overall prevalence of UTI is approximately 2.1 percent in febrile infants but varies widely by race and sex.
Caucasian children have a two- to fourfold higher prevalence of UTI as compared to African-American and Hispanic children
Females have a two- to fourfold higher prevalence of UTI than do males
Caucasian females with a temperature of 39 ºC have a UTI prevalence of 13 percent
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Most common source of serious bacterial infection in children < 2 years
It is a diagnostic challenge by history and physical exam alone
Infants less than 2 years have non specific symptoms
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Easy Quick to perform Inexpensive
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Common practice › young febrile infants who do not have an obvious
source of infection
Requires an invasive procedure.
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Comparison of rapid tests and screening strategies for detecting UTI in infants
Cross-sectional study 3873 children <2 years of age who had a urine
culture obtained in the ED by urethral catheterization
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Urine dipstick tests leukocyte esterase or nitrites
Enhanced urinalysis (UA) (urine white blood cell count/mm3 plus
Gram stain) Compared with urine culture results
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Test positive for nitrite and leucocyte › Specificity of 97%
Test negative for nitrite, LE › Sensitivity of 80%
However, the enhanced UA was the most sensitive (97%) at detecting UTI
Enhanced UA is the preferred method
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Clinical Scenario
A 15 month old female presents with a 2 day history of fever to 40 degrees Celsius and mild URI symptoms. Otherwise she appears healthy.
You suspect a possible UTI. The parents are concerned about the invasiveness of a urine catheterization and do not want to cause harm to their child if the odds of an infection are low.
What are your options at this point? Can you do a bag U/A as a screen?
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Retrospective Study Children younger than 2 years with fever (38°C)
seen in the emergency department during a period of 65 months
Clinical situation that necessitates the collection of a urine culture
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Medical records of 37,450 febrile children
younger than 2 years were reviewed Forty-four percent were females
Median age was 10.6 months Median temperature was 38.8°C
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The sensitivity of the UA was 82% The specificity of UA was 92% A negative UA result decreases the odds of a UTI
5-fold
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If the Prevalence of UTI is less than 2% The risk of missing a UTI because of a false-negative UA result is "acceptable.
1 UTI would be missed for every 250 febrile infants screened by UA
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Age and Sex Males younger than 6 months 5.8% Males older > than 6 months .6%
Females younger than 1 year 3.1 %
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Ethnicity White Females 5% Hispanic Males 2.2%
Temperature greater than or equal to 39°C Females 3.8%
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A 5 month male presents with a 2 day history of fever to 38 degrees Celsius and mild URI symptoms. Otherwise he appears healthy.
Prevalence is 3 %
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Urine Culture should be obtained
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A 7 month male presents with a 2 day history of fever to 38 degrees Celsius and mild URI symptoms. Otherwise he appears healthy.
Prevalence is .6 %
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Consider pre-screening with a Bag UA?
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A 15 month old white female presents with a 2 day history of fever to 38 degrees Celsius and mild URI symptoms. Otherwise she appears healthy.
Prevalence is 3.1 %
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Urine Culture should be obtained
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A 15 month old Hispanic or black female presents with a 2 day history of fever to 38 degrees Celsius and mild URI symptoms. Otherwise she appears healthy
Prevalence .2 %
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Consider pre-screening with a Bag UA?
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Summary
This study suggest that dipstick UA can be used as a screening tool
Offers a recommendation based on prevalence as to when to obtain a urine culture.
If the Prevalence of UTI is less than 2% The risk of missing a UTI because of a false-negative UA result is "acceptable
These patients can then be excluded from further investigation, without the need for confirmatory culture
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References
Bachur R, Harper MB. Reliability of the urinalysis for predicting urinary tract infections in young febrile Division of Emergency Medicine, Arch Pediatr Adolesc Med. 2001 Jan;155(1):60-5.
Shaw KN, Gorelick M, McGowan KL, Yakscoe NM, Schwartz JS. Prevalence of urinary tract infection in febrile young children in the emergency department. Pediatrics. 1998 Aug; 102(2):e16.
Shaw KN, Gorelick M. Urinary tract infection in the pediatric patient. Pediatr Clin North Am. 1999 Dec;46(6):1111-24, vi.
Hoberman A, Urinary tract infections in young febrile children. Pediatr Infect Dis J. 1997 Jan; 16(1):11-7.
Schlager TA. Urinary tract infections in children younger than 5 years of age: epidemiology, diagnosis, treatment, outcomes and prevention. Paediatr Drugs 2001; 3(3):219-27.