The debate continues: is urine culture indicated in neonates with prolonged jaundice?

Abstract

Dear Editor, We read with interest the article by Chowdhury et al. highlighting that urine culture is not an appropriate investigation in neonates with unconjugated prolonged jaundice (PJ) [1]. The authors describe their 5-year experience of managing 319 neonates, where only one neonate had confirmed urinary tract infection (UTI) [1]. They support their argument about inappropriateness of urine culture with two previous studies from the UK where UTI was detected in one patient each [1]. The authors however do not mention whether they have initiated a change of practice. If they have stopped doing urine culture which is not at par with the recommendation made by the NICE guidelines, do they do a urine dipstick as a screening test? [2] Relying on urine dipstickmay be falsely reassuring as neonates do not hold urine in the bladder long enough to demonstrate nitrites [2], thus missing those with asymptomatic bacteriuria without septicemia [3]. While the worldwide geographical difference in incidence of UTI in well neonates with PJ is acknowledged, (recorded as high as 7.5 % [n=12] in a US study of 160 infants aged <8 weeks) [3], this has not been considered for the UK population. A study of 111 well asymptomatic neonates with PJ in Chichester, UK, demonstrated a frequency of UTI at 3.6 % (n=4), supporting the need to send urine cultures in neonates. This is much higher than the other UK studies; urine was also collected by clean catch method as recommended by NICE guidelines, minimizing the chance of contamination [4]. The other important aspect that Chowdhury et al. highlighted was that one asymptomatic neonate, who was treated for UTI, was later diagnosed with renal tract abnormality [1]. This was a significant finding which would have been missed if urine culture was not included in the investigations. Given that infants with renal tract abnormalities (recorded at 55 % [n=6] of all UTIs [n=12] in a US study of 160 infants with PJ) [3] may be asymptomatic but are predisposed to UTIs suggests that a urine culture is a useful investigation to carry out to enable screening for this important diagnosis [3]. Another study from Swindon, UK, with 100 well neonates, diagnosed UTI in one patient who also had structural abnormalities of the renal tract [5]. Although it is cumbersome to collect and follow up urine culture samples, from our experience in managing well neonates with PJ and available literature [3–5] and recommendations made in the NICE guidelines, we support the inclusion of urine culture (preferably collected by clean catch method) in the investigative pathway for all neonates with PJ, as it can be the first sign of a UTI and to identify possibility of associated renal tract abnormalities in an otherwise well, asymptomatic infant [2–5].