December 13, 2019
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Current guidelines may lead to untreated UTIs in children

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Nader Shaikh

Study findings published in The Journal of Pediatrics suggest that following current guidelines for the diagnosis of UTI in children may result in many children with a UTI going untreated, researchers said.

A systematic review and meta-analysis found that the prevalence of asymptomatic bacteriuria (ABU) is “considerably lower” than the prevalence of UTI in most children aged 19 years or younger, the researchers reported.

Although some clinicians are concerned that children who present with ABU and develop a non-localizing febrile illness may be mistakenly diagnosed with a UTI, the researchers said the low prevalence of ABU noted in this study means this will occur “extremely rarely” — suggesting a need to revise AAP guidelines.

“The current guidelines require pyuria or leukocyte esterase to be present when diagnosing a UTI,” Nader Shaikh, MD, MPH, professor of pediatrics at the University of Pittsburg School of Medicine and Children’s Hospital of Pittsburgh, told Healio. “This requirement probably does more harm than good. Had the prevalence of ABU been high relative to the prevalence of [UTI], then this requirement may have benefited children.”

Shaikh estimated that, under current guidelines, for every child with ABU who is not given antibiotics, 12 children with febrile UTI risk going untreated. The CDC recommends against antibiotic treatment for asymptomatic bacteriuria in children and requires urinalysis suggestive of infection with presence of pyuria, nitrites or bacteriuria for a diagnosis of pediatric UTI.

Shaikh and colleagues included 14 studies in their review with data on bacteriuria in 49,806 asymptomatic children aged 19 years or younger who had urine collected via bladder catheterization, bladder aspiration or three consecutive clean catch samples.

ABU prevalence in the studies was 0.47% in girls (95% CI, 0.36%-0.59%) and 0.37% in boys (95% CI, 0.09%-0.82%), with corresponding values for ABU without pyuria of 0.38% (95% CI, 0.22%-0.58%) and 0.18% (95% CI, 0.02%-0.51%), respectively, according to Shaikh and colleagues.

ABU prevalence was previously assumed to be between 1% and 2% on average, Shaikh said, an assumption based primarily on screening programs from the 1950s and 1960s.

“Even though many of these screening programs were aimed at detecting urinary tract infection, and thus included symptomatic children, those with bacteriuria detected in these studies came to be referred to as children with ‘asymptomatic bacteriuria,’” he said.

Circumcised boys aged 1 year or younger and girls aged 2 years or older were the subgroups with the highest ABU prevalence. The prevalence of ABU in boys following infancy was 0.08% (95% CI, 0.01%-0.37%). Median duration of ABU in untreated boys and girls was found to be 1.5 and 2 months, respectively, in the one study that included this outcome.

“Pyuria and leukocyte esterase are not always present in children with UTI. Requiring it will lead to missed UTIs,” Shaikh said. “Until better biomarkers are available, febrile infants should receive the gold standard test for UTI, which is the urine culture. Although a small number of children with ABU may be incorrectly diagnosed with a UTI as a result, this number is far less than the number of children with UTI that are being missed using our current definition of UTI.” – by Eamon Dreisbach

Reference:

CDC. Pediatric Treatment Recommendations. https://www.cdc.gov/antibiotic-use/community/for-hcp/outpatient-hcp/pediatric-treatment-rec.html. Accessed Dec. 12, 2019.

Shaikh N, et al. J Pediatr. 2019;doi:10.1016/j.jpeds.2019.10.019.

Disclosures: The authors report no relevant financial disclosures.