Diagnosis Of Urinary Tract Infection In Children Research Articles

A Review of Urinary Tract Infections in Pediatric Patients

Urinary tract infections (UTIs) are a common and significant health concern in children. The etiology of UTIs in children can vary depending on various factors, including age, gender, and underlying conditions. This comprehensive review aims to explore the etiology, pathogens involved, etiological evaluation by age group, diagnosis, differential diagnosis, follow-up, treatment, and prognosis of UTIs in children. Introduction: Urinary tract infections (UTIs) are bacterial infections that affect the urinary system, comprising the kidneys, ureters, bladder, and urethra. In children, UTIs can cause substantial morbidity if not promptly diagnosed and treated. Understanding the etiology and appropriate management strategies is crucial for healthcare providers involved in the care of pediatric patients. Etiology of UTIs in Children: UTIs in children can have various etiological factors, with the most common cause being bacterial invasion of the urinary tract. The majority of UTIs are caused by Gram-negative bacteria, with Escherichia coli being the predominant pathogen. Other potential pathogens include Klebsiella pneumoniae, Proteus mirabilis, Enterococcus faecalis, and Staphylococcus saprophyticus. Viral and fungal infections can also contribute to UTIs in certain cases. Pathogens Involved in the Etiology of UTIs: A detailed examination of the pathogens involved in UTIs is essential for appropriate diagnosis and treatment. E. coli, which colonizes the gastrointestinal tract, is responsible for the majority of UTIs in children. Understanding the antibiotic resistance patterns of these pathogens is crucial in selecting appropriate antimicrobial therapy. Etiological Evaluation by Age Group: The etiological evaluation of UTIs in children varies according to age group. Infants, young children, and older children may exhibit different risk factors and underlying conditions that contribute to UTIs. An age-specific approach is necessary to identify the potential causes, such as urinary tract abnormalities, voiding dysfunction, or anatomical abnormalities. Diagnosis of UTIs in Children: Accurate and timely diagnosis of UTIs is crucial to prevent complications and recurrent infections. Various diagnostic tools, including urinalysis, urine culture, and imaging studies, aid in identifying UTIs and determining the severity of infection. Clinical symptoms, such as fever, dysuria, and urinary frequency, must also be considered in the diagnostic process. Differential Diagnosis: UTIs can present with symptoms similar to other conditions, leading to diagnostic challenges. Differential diagnoses may include conditions such as pyelonephritis, urinary tract stones, urethritis, and sexually transmitted Open Access Journal of Urology & Nephrology 2 Parlak ME and Kucukkelepce O. A Review of Urinary Tract Infections in Pediatric Patients. J Urol Nephrol 2023, 8(3): 000238. Copyright© Parlak ME and Kucukkelepce O. infections. An understanding of these potential differentials is essential to avoid misdiagnosis and provide appropriate treatment. Follow-up and Monitoring: After initiating treatment for UTIs, regular follow-up and monitoring are necessary to ensure the resolution of infection, assess treatment response, and prevent complications. Monitoring urine culture results, renal function, and imaging studies play a vital role in evaluating the effectiveness of treatment and detecting any underlying conditions that require further management. Treatment of UTIs in Children: Treatment of UTIs in children involves antimicrobial therapy targeted at the identified pathogen. The choice of antibiotics should consider local resistance patterns, age of the child, and severity of infection. Adequate hydration, symptomatic relief, and addressing predisposing factors are also important in the overall management of UTIs. Prognosis: With timely diagnosis and appropriate treatment, the prognosis for UTIs in children is generally favorable. However, the presence of underlying conditions, delayed diagnosis, or recurrent infections can influence the long-term outcome. Identifying and managing risk factors and promoting good urinary hygiene can help prevent future UTIs and potential complications. Conclusion: Urinary tract infections in children present unique challenges in terms of etiology, diagnosis, and management. Understanding the etiological factors, pathogens involved, appropriate diagnostic approaches, and treatment strategies is crucial for healthcare providers. By implementing a comprehensive approach that considers age-specific evaluations, accurate diagnosis, and effective treatment, healthcare professionals can ensure optimal outcomes and reduce the burden of UTIs in children.

EVALUATION OF MODIFIED NITRITE TEST AS A DIAGNOSTIC TEST IN URINARY TRACT INFECTION OF CHILDREN

Objective: Urinary tract infection (UTI) is common infection in children. Urine culture is the gold standard method for diagnosing urine infection but it takes more than 48 h to give results. The objective is to evaluate the diagnostic ability of modified nitrite test as a rapid diagnostic screening test for diagnosis of UTI in children. Methods: An observational and cross-sectional study was conducted in a tertiary care hospital in Udaipur over a period of 1 year. Children aged up to 60 months with suspected UTI were enrolled in the study. Children with congenital urogenital anomalies and prior antibiotic treatment were excluded from the study. Urine culture and modified nitrite test was done for every children. Results: Ninety children with suspected UTI were enrolled in the study. Urine culture was positive in 14 (15.55%) out of 90 urine samples. When modified nitrite test was compared to positive urine culture, true positives were 9 and 1 was false positive. Sensitivity, Specificity, PPV, NPV, and Accuracy was 64.29%, 98.68%, 90%, 93.75%, and 93.33%, respectively. Conclusion: Sensitivity and specificity of modified nitrite test are good enough as a diagnostic test for detection of UTI. It can be used as a point of care test for rapid screening and identifying the cases.

Assessment of Parents' Awareness of Urinary Tract Infections (UTIs) in Infants and Children and Related Demographic Factors: A Cross-sectional Study

Background: Urinary tract infection (UTI) is the second most common infection in children. Parents’ lack of awareness and information about UTIs ultimately leads to delayed referral for treatment, which raises many concerns in parents. Objectives: The research aimed to evaluate the parental awareness of UTIs in infants and children and related demographic factors. Methods: In this cross-sectional analytical study, 270 parents who had a child or infant with UTIs referring to the Nephrology Clinic of Mohammad Kermanshahi Hospital in Kermanshah, Iran, in 2018 were selected by a convenience sampling method. To analyze the data, the chi-square test and Fisher's exact test were used. Results: According to the results, the parental awareness of the symptoms of UTIs in children was moderate, and the overall score on the awareness of complications, treatment, prevention, and diagnosis of UTIs in children was high. There were statistically significant relationships between the parental age and knowledge of UTI treatment in children, between paternal education and treatment and diagnosis and the total score of knowledge on UTIs in children, and between maternal education and awareness of the symptoms and how to prevent UTIs. Further, there was a statistical relationship between the children’s history of UTIs and the awareness of how to diagnose and treat UTIs in children (P < 0.05). Conclusions: Given the results, educational programs must be promoted to raise parents' awareness of UTIs in infants and children, especially UTI symptoms in lower educated, elderly parents whose other children have not had any history of UTIs.

Discriminatory Precision of Neutrophil Gelatinase-Associated Lipocalin in Detection of Urinary Tract Infection in Children: a Systematic Review and Meta-Analysis.

There is a significant discrepancy between studies on diagnostic precision of neutrophil gelatinase-associated lipocalin (NGAL) in diagnosis of urinary tract infection (UTI). Therefore, the present systematic review and meta-analysis was designed to assess the diagnostic value of NGAL in diagnosis of UTI in children and adolescents. An extensive search was performed on Medline, Embase, Scopus and Web of Science databases by the end of 2019. Two independent researchers screened and summarized the data. Discriminatory precision of urinary and serum NGAL was assessed by reporting area under the curve, sensitivity, specificity and diagnostic odds ratio with 95% confidence interval (95% CI). Data from 12 studies were included. The area under the curve of urinary and serum NGAL for diagnosis of UTI in children and adolescents at the best cut-off point (between 30-39.9 ng/ml) was 0.95 (95% CI: 0.93 to 0.97) and 0.83 (95% CI: 0.80 to 0.86), respectively. Sensitivity, specificity and diagnostic odds ratio on urinary NGAL at these cut-off points were 0.89 (95% CI: 0.64 to 0.97), 0.89 (95% CI: 0.71 to 0.97) and 67 (95% CI: 5 to 891), respectively. Sensitivity, specificity and diagnostic odds ratio of serum NGAL in UTI detection were 0.85 (95% CI: 0.70 to 0.90), 0.81 (95% CI: 0.69 to 0.88) and 9.53 (95% CI: 1.52 to 59.65), respectively. The present meta-analysis showed that urinary NGAL had a high diagnostic value in detection of UTI in children and adolescents with an optimum cut-off point in the range of 30-39.9 ng/ml.

Diagnostic value of urinary interleukin-6 in urinary tract infection in children.

Introduction Urinary tract infection (UTI) is the second most common bacterial infection in children. Aim of the study To estimate the value of urinary Interleukin-6 (IL-6) in diagnosis of UTI in children and also if it can differentiate between upper and lower UTI. Patients and Methods This study included 80 children, divided into 40 patients suffering from UTI and 40 healthy children served as a control group. Patients were classified into acute pyelonephritis (n=22) and lower UTI (n=18). Urine IL-6 was measured by enzyme-linked immune- sorbent assay (ELISA) technique. Results Urinary IL-6 was significantly higher in patients with UTI than control group (p value <0.001) and also it was significantly higher in upper than lower UTI cases (p value <0.001). Conclusion Urinary IL-6 level is a reliable diagnostic tool for early identification of UTI in febrile children. The study confirms usefulness of Urinary IL-6 level is a reliable diagnostic tool for early identification of urinary IL-6 to differentiate between upper and lower UTIs.

Long-term outcomes of urinary tract infection (UTI) in childhood: The LUCI study

Background Guidelines recommend the prompt diagnosis and treatment of UTI in young children to reduce the risk of renal scarring and possible long-term complications. However, the evidence for this association is weak and has been questioned. There is an urgent need to clarify this as the correct approach to urine sampling and diagnosis of UTI in children hinges on this association.&#x0D; Main Aim Determine outcomes following UTI in childhood (&lt;5years)&#x0D; Approach We used the Secure Anonymised Information Linkage (SAIL) Databank to access demographic, hospital, GP and microbiology data from children in Wales. Children with &gt;1 microbiologically confirmed UTI (mcUTI) aged &lt;5, were compared to those with no mcUTI. The primary outcome was renal scarring and secondary outcomes included hypertension, chronic kidney disease and renal failure. The primary analysis used multinomial regression and time to event models.&#x0D; Results A cohort of 159,201 children was defined. 11,099 (7.0%) had &gt;1 mcUTI.&#x0D; The overall prevalence of renal scarring in the cohort by age 7 was 0.16%; 1.26% in those with &gt;1 mcUTI; 0.08% in those with no mcUTI. The unadjusted odds ratio (OR) was 16.62 (12.91-21.39) and adjusted 3.64 (2.57-5.14). Among the group with &gt;1 mcUTI, predictors of renal scarring were VUR, younger age of first UTI, and greater number of UTIs &lt;5&#x0D; Conclusion UTI was associated with renal scarring even after adjusting for covariates.&#x0D; The prevalence of renal scarring in children with &gt;1 mcUTI was lower than expected. Possible explanations include poor coding in routine data, different patient populations or missed renal scarring diagnoses. We are currently validating our results using radiology data. If renal scarring diagnoses are being missed, a more proactive urine sampling and imaging strategy may be indicated. However, if renal scarring rates are low following UTI, this may not be necessary.

Collecting the golden water: Quality assessment on approach of diagnosing urinary tract infections in 0 to 36 months old children.

The study aimed to assess current practices of a community hospital for collection of urine sample when diagnosis of urinary tract infection (UTI) is suspected in children aged 0 to 36 months old. An analysis of paediatric patients aged 0 to 36 months old was performed in two separate audits to assess the quality of urine sampling. The first, retrospective analysis comprised of urine collections techniques in a community hospital for diagnosis of UTI followed by an education intervention in which the hospital staff was briefed regarding the Canadian Paediatric Society (CPS) position statement for diagnosis and management of UTI. CPS recommendations were transposed using PowerPoint presentations, reminders at unit huddles, and other educational forums. Second audit was a prospective analysis which was conducted 6 months after the educations intervention. Bagged sampling had higher sensitivity and lower specificity due to sample contamination, versus transurethral bladder catheterization and suprapubic aspiration. The first audit showed that while 66% of culture-positive urine sampling was performed via the bagging, only 26% those positive cultures were repeated before treatment. In the second audit, after educational intervention, 33% of culture-positive urine collection was done via the bagging method and repeat testing was done in 83% of positive results on a bagged sample before initiating treatment. The false-positive rate for the diagnosis of UTIs in the first and second audit was 65.7 and 60%, respectively. Our study recognizes the flaws in community hospital practices in the diagnosis of UTI in children and validates the significance of educational intervention in improving health care.

Prevalence of urinary tract infection among preschool febrile children attending the pediatric OPD

Background: Urinary tract infection (UTI) is one of the most common bacterial illness among febrile infants and preschool children with a reported prevalence between 4.1% and 7.5%. The objective of this study was to know the prevalence of urinary tract infection in preschool febrile children.Methods: Cross sectional study conducted in pediatric OPD of a Government teaching hospital with 500 febrile preschool children aged 3 to 6 years. Results: Prevalence of UTI in febrile preschool children aged 3-6 years was 2.9% in males and 5.5% in females with overall prevalence of 4%. 15% had temperature &gt; 39.3 oC. 45% had dysuria, 35% had vomiting. 25% and 20% had increased frequency and burning micturition respectively. 70% patients with UTI and 30% cases without UTI had proteinuria. 95% patients had pus cells &gt; 5 per HPF. 60% patients had bacteria in their urine where as in culture negative cases only 1.04% had bacteria. E coli was the common organism isolated (80%), followed by Klebsiella. Majority were resistant to Ampicillin (55%). 75% of microorganisms were sensitive to ceftriaxone. 70% were sensitive to gentamycin, norfloxacin and cephalexin. 5% UTI cases had RFT. KUB X-ray was normal in all the cases. 20% of cases showed features suggestive of acute pyelonephritis on Ultrasonography. 1 out of 4 Patients who underwent Intravenous pyelography showed hydronephrosis. 2 out of 4 cases showed VUR in MCU.Conclusions: UTI is a potential cause of fever in children below 6 years of age. Urine culture is the gold standard for diagnosis of UTI in children. Parents should be educated about the importance of UTI and its long-term complications.

Management of UTI in Children: Murky Waters.

* Abbreviations: AAP — : American Academy of Pediatrics UTI — : urinary tract infection Over the course of the last 2 decades, the approach to the management of urinary tract infections (UTIs) in children has undergone considerable reconsideration. Areas such as screening urinalysis, method of urine collection, definition of a positive culture, imaging assessment after the diagnosis of UTI in children, medications for treatment, and mode of administration are examples of such reassessment. In 2011, American Academy of Pediatrics (AAP) guidelines for the diagnosis and management of UTI in febrile infants and young children were published.1 The guidelines were for children 2 to 24 months. However, the guidelines also provide a framework for … Address correspondence to Aaron Friedman, MD, 125 North Hamilton St, #905, Madison, WI 53703. E-mail: alfried{at}umn.edu

Clinical and laboratory profile of urinary tract infection in febrile children aged 1 to 5 years

Background: Urinary tract infection (UTI) is a common problem in the pediatric age group and is a significant risk factor for long term sequelae. The clinical signs and symptoms of UTI are nonspecific and vague in the first 6 years of age. The aim was t o study the prevalence of urinary tract infection in 500 febrile children. Methods: This is a cross-sectional study in which 500 febrile children aged 1 to 5 years who attended pediatric outpatient department were selected, detailed history was taken and clinical examination was done in all the cases to find out the cause of fever. Necessary investigations were carried out to find the cause of fever and all the data were recorded in a specially designed proforma for this study . Results: Prevalence of UTI in febrile children in the age group of 1-5 years was 2.9% in males and 5.5% in females with overall estimated prevalence of 4%. The most common organism isolated from patients with UTI was E. coli. Ultrasonographic features suggestive of acute pyelonephritis were found in 20% of cases with UTI. Micturating cysto-urethrogram (MCU) showed vesicoureteral reflux (VUR) in 2 cases. Conclusions: UTI should be considered as a potential cause of fever in children below 5 years of age. As the febrile children with UTI usually present with nonspecific signs and symptoms, urine culture should be considered as a part of diagnostic evaluation. Urine culture is the gold standard for diagnosis of UTI in children. Parents should be educated about the importance of UTI and its long term complications so that they bring the children voluntarily for regular follow up.

Do English NHS Microbiology laboratories offer adequate services for the diagnosis of UTI in children? Healthcare Quality Improvement Partnership (HQIP) Audit of Standard Operational Procedures.

The National Institute of Care Excellence (NICE) 2007 guidance CG54, on urinary tract infection (UTI) in children, states that clinicians should use urgent microscopy and culture as the preferred method for diagnosing UTI in the hospital setting for severe illness in children under 3 years old and from the GP setting in children under 3 years old with intermediate risk of severe illness. NICE also recommends that all ‘infants and children with atypical UTI (including non-Escherichia coli infections) should have renal imaging after a first infection’. We surveyed all microbiology laboratories in England with Clinical Pathology Accreditation to determine standard operating procedures (SOPs) for urgent microscopy, culture and reporting of children's urine and to ascertain whether the SOPs facilitate compliance with NICE guidance. We undertook a computer search in six microbiology laboratories in south-west England to determine urine submissions and urine reports in children under 3 years. Seventy-three per cent of laboratories (110/150) participated. Enterobacteriaceae that were not E. coli were reported only as coliforms (rather than non-E. coli coliforms) by 61 % (67/110) of laboratories. Eighty-eight per cent of laboratories (97/110) provided urgent microscopy for hospital and 54 % for general practice (GP) paediatric urines; 61 % of laboratories (confidence interval 52–70 %) cultured 1 μl volume of urine, which equates to one colony if the bacterial load is 106 c.f.u. l− 1. Only 22 % (24/110) of laboratories reported non-E. coli coliforms and provided urgent microscopy for both hospital and GP childhood urines; only three laboratories also cultured a 5 μl volume of urine. Only one of six laboratories in our submission audit had a significant increase in urine submissions and urines reported from children less than 3 years old between the predicted pre-2007 level in the absence of guidance and the 2008 level following publication of the NICE guidance. Less than a quarter of laboratories were providing a service that would allow clinicians to fully comply with the first line recommendations in the 2007 NICE UTI in children guidance. Laboratory urine submission report figures suggest that the guidance has not led to an increase in diagnosis of UTI in children under 3 years old.

Lipopolysaccharide-binding protein: a potential marker of febrile urinary tract infection in childhood

Urinary tract infections (UTIs) are encountered frequently in children, and their early diagnosis and treatment are important. This study evaluates the diagnostic value of serum concentrations of lipopolysaccharide-binding protein (LBP), an acute-phase protein, in children with febrile UTI and compares it to those of the total white blood cell count (WBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), procalcitonin (PCT), and interleukin-6 (IL-6). The study population comprised 77 consecutive patients with a first-episode febrile UTI (33 boys) with a median age of 11 months [interquartile range (IQR), 5.5-33 months], 21 healthy controls (11 boys) with a median age of 10 months (IQR, 5-20.5 months) and 58 febrile controls with a fever due to other causes (28 boys) with a median age of 12.5 months (IQR, 7-30 months). LBP, IL-6, PCT, and CRP were measured for both patients and control groups. The serum levels of LBP (p < 0.001), CRP (p < 0.001), PCT (p = 0.001), IL-6 (p = 0.002), ESR (p = 0.020), and WBC (p < 0.001) were higher in patients with febrile UTI than in the healthy and febrile control groups. The LPB cut-off value for best sensitivity and specificity in patients with febrile UTI was >43.23 mg/l. Furthermore, the area under the receiver operating characteristic curve was significantly greater for LBP than for CRP (p = 0.014), PCT (p < 0.001), ESR (p < 0.001), WBC (p = 0.002) and IL-6 (p = 0.006). The results of this study suggest that the serum LBP concentration constitutes a reliable biologic marker for the diagnosis of a febrile UTI in children.

Is Culture-positive Urinary Tract Infection in Febrile Children Accurately Identified by Urine Dipstick or Microanalysis?

BackgroundFever from a urinary tract source remains the predominant etiology of serious bacterial infection in children ages 0–36 months. Urine culture is the gold standard for diagnosing a urinary tract infection (UTI); however, urine dipstick (UDip) and urine microanalysis (UA) are typically used real time by Emergency Physicians to diagnose and treat UTIs, as cultures can take days to grow and be available. The purpose of this article is to evaluate the literature on the accuracy and utility of the UDip and UA in this pediatric population. MethodsA structured review of the medical literature to determine the accuracy of UDip and UA for the diagnosis of UTI in children before the result of the urine culture. ResultsUpon comprehensive review and after applying predefined inclusion criteria, a total of 13 articles met inclusion criteria, addressed the clinical question, and were reviewed in detail. ConclusionsThe literature search did not conclusively identify any component of either the UDip or the UA, which would allow a practitioner to conclude definitively that the source of an infant's fever is a UTI.

Diagnostic performance of urine dipstick testing in children with suspected UTI: a systematic review of relationship with age and comparison with microscopy

Prompt diagnosis of urinary tract infection (UTI) in children is needed to initiate treatment but is difficult to establish without urine testing, and reliance on culture leads to delay. Urine dipsticks are often used as an alternative to microscopy, although the diagnostic performance of dipsticks at different ages has not been established systematically. Studies comparing urine dipstick testing in infants versus older children and urine dipstick versus microscopy were systematically searched and reviewed. Meta-analysis of available studies was conducted. Six studies addressed these questions. The results of meta-analysis showed that the performance of urine dipstick testing was significantly less in the younger children when compared with older children (p < 0.01). Positive likelihood ratio (LR) of both nitrite and leucocyte positive 38.54 [95% confidence interval (CI) 22.49-65.31], negative LR for both negative 0.13 (95% CI 0.07-0.25) are reasonably good, and those for young infants are less reliable [positive LR 7.62 (95% CI 0.95-51.85) and negative LR 0.34 (95% CI 0.66-0.15)]. Comparing microscopy and urine dipstick testing, using bacterial colony count on urine culture showed no significant difference between the two methods. Urine dipstick testing is more effective for diagnosis of UTI in children over 2 years than for younger children.

How do Dutch general practitioners diagnose children's urinary tract infections?

To study which tests general practitioners used to diagnose a urinary tract infection (UTI) in children and which patient characteristics were associated with test choice. Retrospective chart review on the diagnosis of UTIs in children in Dutch general practices who were diagnosed as having a UTI. A total of 49 general practices participated in the study, and provided information on 148 children aged 0-12 years old. The nitrite test, which is recommended as first step, was performed in 87% of the children during the first contact. Less than 30% of the children had a dipslide and 37% a cultured urine. About half of all children with a UTI diagnosis had a follow-up contact in general practice, and an average of 83% of these children had their urine tested. The recommended test, a dipslide, was performed in 26% of the children with a follow-up contact. Patient age and UTI history were associated with choice of test. The diagnostic procedures for UTIs in children in general practices could be improved, with focus on the importance of an accurate UTI diagnosis in all children, and explaining which tests should be performed and what the test results mean.

Clinical effectiveness and cost-effectiveness of tests for the diagnosis and investigation of urinary tract infection in children: a systematic review and economic model

To determine the diagnostic accuracy of tests for detecting urinary tract infection (UTI) in children under 5 years of age and to evaluate the effectiveness of tests used to investigate further children with confirmed UTI. Also, to evaluate the effectiveness of following up children with UTI and the cost-effectiveness of diagnostic and imaging tests for the diagnosis and follow-up of UTI in children under 5. An additional objective was to develop a preliminary diagnostic algorithm for healthcare professionals. Electronic databases were searched up to the end of 2002/early 2003. Consultation with experts in the field. A systematic review was undertaken using published guidelines and results were analysed according to test grouping: diagnosis of UTI and further investigation of UTI. The cost-effectiveness results from existing evaluations were synthesised. A separate cost-effectiveness model was developed using the best available evidence, in part derived from the results of the systematic review, to illustrate the potential cost-effectiveness of some alternative management strategies in a UK setting. The results of the systematic review were used to propose diagnostic algorithms for the diagnosis and further investigation of UTI in children. Economic analyses did not contribute directly to the development of these algorithms. The studies included in the review provided very little data on the accuracy of clinical investigations for the diagnosis of UTI, and criteria for clinical suspicion of UTI were not further defined. The majority of studies included in the review found that clean voided midstream urine (CVU) samples had similar accuracy to suprapubic aspiration (SPA) samples when cultured with the advantage of being a non-invasive collection method that can be used in the GP's surgery. Pad, nappy or bag specimens may be appropriate methods for obtaining a urine sample in non-toilet-trained children, although only limited data were available. Although the glucose test was reported to have the highest accuracy in terms of both ruling in and ruling out disease, only a limited number of studies of this test were included and these were conducted over 30 years ago. Dipstick tests are easy to perform in the GP's surgery, give an immediate result and are relatively cheap. The results of the systematic review showed that a dipstick for leucocyte esterase (LE) and nitrite, where both test results are interpreted in combination, was a good test both for ruling in (both positive) and ruling out (both negative) a UTI. A dipstick positive for either LE or nitrite and negative for the other provides inconclusive diagnostic information and further testing is therefore required in these patients. Microscopy is more time consuming and expensive to perform than a dipstick test, but potentially quicker and cheaper than culture. As with dipstick tests, a combination of microscopy for pyuria and bacteriuria can be used accurately to rule in and rule out a UTI. An indeterminate test result is again obtained if microscopy is positive for either pyuria or bacteriuria, and negative for the other. Confirmatory culture is required in these patients. In patients considered to have a UTI, further culture to determine antibiotic sensitivities may be an option to inform treatment decisions. Only one study satisfied the inclusion criteria of the economic review and the review highlighted a number of potential limitations of this study for NHS decision-making. A separate decision-analytic model was therefore developed to provide a more reliable estimate of the optimal strategy regarding the diagnosis and further investigation of children under 5 with suspected UTI from the perspective of the NHS. The economic model found that the optimal diagnostic strategy for children presenting with symptoms suggestive of UTI depends on a number of key factors. These included the relevant subgroup of children concerned, in terms of gender and age, and the health service's maximum willingness to pay for an additional quality-adjusted life-year. The results of the systematic review were used to derive an algorithm for the diagnosis of UTI in children under 5. This algorithm represents the conclusions of the review in terms of effective practice. There were insufficient data to propose an algorithm for the further investigation of UTI in children under 5. The quality assessment highlighted several areas that could be improved upon in future diagnostic accuracy studies.

Diagnosis and management of urinary tract infection in children.

Urinary tract infection (UTI) causes significant illness, particularly in the first two years of life, and has the potential to cause permanent renal damage. Diagnosis of UTI in children is dependent on the collection of an uncontaminated freshly voided urine sample, which is key to the future management and follow-up of these patients. Prevention of possible long-term renal damage remains a priority.

Screening tests for urinary tract infection in children: A meta-analysis.

To review systematically and to summarize the existing literature regarding performance of rapid diagnostic tests for urinary tract infection (UTI) in children. Systematic review and meta-analysis. Published articles reporting the performance of urine dipstick tests (leukocyte esterase [LE] and/or nitrite), Gram stain, or microscopic analysis of spun or unspun urine in the diagnosis of UTI in children </=12 years of age. Articles were identified through a comprehensive MEDLINE search, and those articles meeting a priori inclusion criteria were selected. Eligibility criteria included the use of urine culture as the reference standard, independent comparison of urine culture with the results of one of the screening tests, definition of positive screening test results provided, only pediatric patients included or evaluable separately, and both gold standard and screening test performed on all patients. For each test, heterogeneity of reported sensitivity and specificity of all studies was determined. The subgroups of studies with similar definitions of UTI and age of study subjects were analyzed separately to account for some of the differences in reported results. When significant unexplained heterogeneity among studies precluded simple combining of results, a summary receiver-operator characteristic curve was fitted for each screening test, from which pooled estimates of true-positive rate (TPR; ie, sensitivity) and false-positive rate (FPR; 1-specificity) were calculated. A total of 1489 titles were identified by the MEDLINE search; 26 articles met all criteria for inclusion. There was significant heterogeneity among studies for nearly all tests for both TPR and FPR, which was explained only partially by the stringency of the definition of UTI or age of subjects studied. Based on the pooled estimates, the presence of any bacteria on Gram stain on an uncentrifuged urine specimen had the best combination of sensitivity (0.93) and FPR (0.05). Urine dipstick tests performed nearly as well, with a sensitivity of 0.88 for the the presence of either LE or nitrite and an FPR of 0.04 for the presence of both LE and nitrite. Pyuria had lower TPR and higher FPR: for presence of >5 white blood cells/high-power field in a centrifuged urine sample, the TPR was 0.67 and the FPR was 0.21, whereas for >10 white blood cells per mm(3) in uncentrifuged urine, the TPR was 0.77 and the FPR was 0.11. Both Gram stain and dipstick analysis for nitrite and LE perform similarly in detecting UTI in children and are superior to microscopic analysis for pyuria.