Urinary tract infection controversy and questions.

Abstract

To the Editor. In my 25 years of reading Pediatrics I have never before been moved to write—but the article by Kramer and Shapiro in the July 19971 issue was such a breath of fresh air that I could not resist. As a practicing pediatrician I spend most of my time dealing with the “denominators,” with the 600 or so febrile children between 3 and 36 months who must be poked and catheterized, who must endure long waits in crowded emergency rooms, who must risk not only iatrogenic injury by a resident's first lumbar puncture, or a gentamicin overdose by an overworked nurse, but also the horror of having their electrocardiogram leads mistakenly plugged into a 110-volt wall outlet—all to avoid “missing” the one child who might be harboring a life-threatening bacteremia or early meningitis. I agree with Kramer and Shapiro that the “soft” morbidity associated with the “rule-out” (as it is commonly abbreviated at our local children's hospital) is considerable, if not easily measurable. I see it surface later on as the vulnerable child syndrome, with parents either overprotective or afraid to set limits for their toddler. I hear it as patients new to the practice relate a past history including phrases like “the doctor said if we'd gotten there a half-hour later, we would have lost her.” I also appreciate the commentaries following Kramer and Shapiro's article. Certainly studies must continue to be done and randomization must be performed. How else can we obtain the data that enables me to sit down with the parents of a nontoxic toddler with a fever of 104°F and a clean urine and explain that there is a 1 in 600 chance that their child might have a dangerous bloodstream infection, but that I would recommend watchful waiting and a return …