Professional Documents
Culture Documents
Diagnostic Accuracy of The Urinalysis For Urinary Tract Infections in Infants Less Than 3 Months of Age
Diagnostic Accuracy of The Urinalysis For Urinary Tract Infections in Infants Less Than 3 Months of Age
BACKGROUND:The 2011 American Academy of Pediatrics urinary tract infection (UTI) guideline abstract
suggests incorporation of a positive urinalysis (UA) into the definition of UTI. However,
concerns linger over UA sensitivity in young infants. Infants with the same pathogenic
organism in the blood and urine (bacteremic UTI) have true infections and represent
a desirable population for examination of UA sensitivity.
METHODS:We collected UA results on a cross-sectional sample of 276 infants ,3 months of
age with bacteremic UTI from 11 hospital systems. Sensitivity was calculated on infants
who had at least a partial UA performed and had $50 000 colony-forming units per milliliter
from the urine culture. Specificity was determined by using a random sample of infants
from the central study site with negative urine cultures.
The final sample included 245 infants with bacteremic UTI and 115 infants with
RESULTS:
negative urine cultures. The sensitivity of leukocyte esterase was 97.6% (95% confidence
interval [CI] 94.5%–99.2%) and of pyuria (.3 white blood cells/high-power field) was 96%
(95% CI 92.5%–98.1%). Only 1 infant with bacteremic UTI (Group B Streptococcus) and
a complete UA had an entirely negative UA. In infants with negative urine cultures, leukocyte
esterase specificity was 93.9% (95% CI 87.9 – 97.5) and of pyuria was 91.3% (84.6%–95.6%).
CONCLUSIONS:In young infants with bacteremic UTI, UA sensitivity is higher than previous
reports in infants with UTI in general. This finding can be explained by spectrum bias or by
inclusion of faulty gold standards (contaminants or asymptomatic bacteriuria) in previous
studies.
a
Department of Pediatrics, Santa Clara Valley Medical Center, San Jose, California; bDepartment of Pediatrics, WHAT’S KNOWN ON THIS SUBJECT: The
Kaiser Permanente Northern California, Oakland, California; cDepartment of Pediatrics, Dell Children’s Medical
Center, Austin, Texas; and dDepartment of Pediatrics, University of Rochester, Rochester, New York sensitivity of the urinalysis (UA) traditionally has
been considered suboptimal in young infants.
Dr Schroeder conceptualized and designed the initial study, coordinated data collection from all of
the sites, carried out the analysis and interpretation of data, and drafted the manuscript; Drs Shen, Whether the finding of a negative UA and
Chang, and Greenhow conceptualized and designed the initial study, coordinated or co-coordinated a positive urine culture represents a false-
data collection at each of their respective sites, and reviewed and revised the manuscript; negative UA versus a false-positive urine culture
Dr Biondi coordinated data collection for all of the participating Pediatric Research in the Inpatient
remains unclear.
Setting sites, and reviewed and revised the manuscript; and all authors approved the final
manuscript as submitted. WHAT THIS STUDY ADDS: In infants ,3 months
www.pediatrics.org/cgi/doi/10.1542/peds.2015-0012 with bacteremic urinary tract infection,
DOI: 10.1542/peds.2015-0012 a condition that represents true infection, the UA
Accepted for publication Mar 2, 2015 sensitivity is higher than previously reported for
Address correspondence to Alan R. Schroeder, MD, Department of Pediatrics, Santa Clara Valley urinary tract infection in general, suggesting that
Medical Center, 751 S. Bascom Ave, San Jose, CA 95128. E-mail: Alan.Schroeder@hhs.sccgov.org. the UA is reliable even in young infants.
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2015 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
COMPANION PAPER: A companion to this article can be found on page 1126, and online at www.pediatrics.org/cgi/doi/10.1542/peds.2015-0884.
REFERENCES
1. Bachur R, Harper MB. Reliability of the management of the initial UTI in febrile 7. Hoberman A, Wald ER, Reynolds EA,
urinalysis for predicting urinary tract infants and children 2 to 24 months. Penchansky L, Charron M. Is urine
infections in young febrile children. Pediatrics. 2011;128(3):595–610 culture necessary to rule out urinary
Arch Pediatr Adolesc Med. 2001;155(1): 5. Shaw KN, McGowan KL, Gorelick MH, tract infection in young febrile
60–65 Schwartz JS. Screening for urinary tract children? Pediatr Infect Dis J. 1996;
2. Bonadio W, Maida G. Urinary tract infection in infants in the emergency 15(4):304–309
infection in outpatient febrile infants department: which test is best? 8. Wettergren B, Hellström M, Stokland E,
younger than 30 days of age: a 10-year Pediatrics. 1998;101(6). Available at: Jodal U. Six year follow up of infants with
evaluation. Pediatr Infect Dis J. 2014; www.pediatrics.org/cgi/content/full/101/ bacteriuria on screening. BMJ. 1990;
33(4):342–344 6/E1 301(6756):845–848
3. Hoberman A, Wald ER. Urinary tract 6. Newman TB, Bernzweig JA, Takayama JI, 9. Wettergren B, Jodal U. Spontaneous
infections in young febrile children. Finch SA, Wasserman RC, Pantell RH. clearance of asymptomatic bacteriuria
Pediatr Infect Dis J. 1997;16(1):11–17 Urine testing and urinary tract in infants. Acta Paediatr Scand. 1990;
4. Roberts KB; Subcommittee on Urinary infections in febrile infants seen in 79(3):300–304
Tract Infection, Steering Committee on office settings: the Pediatric Research 10. Roberts KB, Charney E, Sweren RJ, et al.
Quality Improvement and Management. in Office Settings’ Febrile Infant Study. Urinary tract infection in infants with
Urinary tract infection: clinical practice Arch Pediatr Adolesc Med. 2002;156(1): unexplained fever: a collaborative study.
guideline for the diagnosis and 44–54 J Pediatr. 1983;103(6):864–867
Updated Information & including high resolution figures, can be found at:
Services http://pediatrics.aappublications.org/content/135/6/965
References This article cites 23 articles, 7 of which you can access for free at:
http://pediatrics.aappublications.org/content/135/6/965#BIBL
Subspecialty Collections This article, along with others on similar topics, appears in the
following collection(s):
Evidence-Based Medicine
http://www.aappublications.org/cgi/collection/evidence-based_medic
ine_sub
Infectious Disease
http://www.aappublications.org/cgi/collection/infectious_diseases_su
b
Permissions & Licensing Information about reproducing this article in parts (figures, tables) or
in its entirety can be found online at:
http://www.aappublications.org/site/misc/Permissions.xhtml
Reprints Information about ordering reprints can be found online:
http://www.aappublications.org/site/misc/reprints.xhtml
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/135/6/965
Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. Pediatrics is owned, published, and trademarked by
the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,
60007. Copyright © 2015 by the American Academy of Pediatrics. All rights reserved. Print
ISSN: 1073-0397.