Rule Out UTI

Shaikh N et al. Prevalence of urinary tract infections in childhood. A meta- analysis. Ped Infect Dis J 2008

Prevalence of Disease - Girls

3 – 6 mos: 5% or 1/20

6 – 12 mos: 8% or 1/12

12 – 24 mos: 2% or 1/50

Prevalence - Males

Uncirc: 3 – 12 mos: 5-7% or 1/16- 1/20

Circ: 3 – 12 mos: 2% or 1/50

Reducing the number of tests by risk stratification

Marc Gorelick, Kathy Shaw, A. Hoberman

Clinical decision rule to identify febrile young girls at risk for urinary tract infection. Arch Pediatr Adolesc Med 2000.

Validation of a decision rule identifying febrile young girls at high risk for urinary tract infection. Ped Emerg Care 2003.

Decision Rule? – No

Decision Guideline? - Yes

Decision Guideline Excludes:

Kids with obvious bacterial cause of fever – meningitis, pneumonia, strep pharyngitis

Kids with definitive viral dx – Varicella, Coxsackie, Herpetic stomatitis

Kids with HSP, Kawasaki’s

Girls < 2 years

• 2 or more of:»T > 39oC»white»age < 12 months»no other source of fever»fever > 2 days

• past history of UTI

• symptoms specific to UTI

13 m Hisp female with 103 fever

Fever for one day

URI on exam

No hx of UTI or UTI sx

= No need to do U/A

9 m Cauc female with 101.5

Fever for 3 days

No URI or AGE

No hx of UTI or UTI sx

= Get a urine

Boys < 1 year

• uncircumcised, or

• age < 6 months and no other source of fever

• past history of UTI

• symptoms specific to UTI

Diagnostic Testing

Urine dipstick for LE, Nitrite

What is a positive?

1+ LE or greater

+ Nitrite whether or not LE is positive

Dip - Diagnostic Accuracy:

Sensitivity ~ 85%

Specificity ~ 90%

After dip, what is chance of disease?

Dip negative – if chance of UTI was ~ 1/20, now ~ 1/120

Dip positive – if chance of UTI was ~ 1/20, now between 1/2 to 1/3 chance

Eliminate the Gram Stain in Kids Over 3 months

Cystitis and Urine Culturing

Cystitis must be clearly defined

Considering Eliminating Culture

Dysuria, frequency. Age > 3 years No evidence of upper tract disease –

fever, back pain, vomiting, abd pain. No UTI in the last year LE and Nitrite Positive No chance of Herpes Labialis or STD