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Ann Fam Med. 2016 Jul;14(4):325-36. doi: 10.1370/afm.1954.

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

Author information

1
Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Clifton, Bristol, United Kingdom alastair.hay@bristol.ac.uk.
2
School of Social and Community Medicine, University of Bristol, Clifton, Bristol, United Kingdom.
3
South East Wales Trials Unit (SEWTU), Centre for Trials Research, Cardiff University, Heath Park, Cardiff, United Kingdom.
4
Primary Care and Population Science, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, United Kingdom.
5
Guys' and St Thomas' Charity Chair in Primary Care Research, NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, Department of Primary Care and Public Health Sciences, London, United Kingdom.
6
Specialist Antimicrobial Chemotherapy Unit, Public Health Wales Microbiology Cardiff, University Hospital Wales, Heath Park, Cardiff, United Kingdom.
7
North Bristol NHS Trust, Southmead Hospital, Westbury-on-Trym, Bristol, United Kingdom.
8
Division of Population Medicine, School of Medicine, Cardiff University, Heath Park, Cardiff, United Kingdom.
9
Bristol Royal Hospital for Children, University Hospitals Bristol, NHS Foundation Trust, Bristol, United Kingdom.
10
Department of Paediatrics and Child Health, University Hospital of Wales, Heath Park, Cardiff, United Kingdom.
11
Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Clifton, Bristol, United Kingdom.
12
King's College London, Division of Health and Social Care Research, Department of Primary Care and Public Health Sciences, London, United Kingdom.
13
NIHR CLAHRC West, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom.
14
Nuffield Department of Primary Care Health Sciences, University of Oxford, New Radcliffe House, Radcliffe Observatory Quarter, Oxford, United Kingdom, and General Practitioner, Cwm Taf University Health Board, Wales, United Kingdom.

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.

METHODS:

We 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 points-based (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.

KEYWORDS:

anti-bacterial agents; diagnosis; pediatrics; primary health care; urinary tract infections

PMID:
27401420
PMCID:
PMC4940462
DOI:
10.1370/afm.1954
[Indexed for MEDLINE]
Free PMC Article

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