Ep 123 Pediatric UTI Myths and Misperceptions

On the one hand, UTI is one of the most common bacterial infections in children younger than 2 years of age and could lead to sepsis acutely and theoretically renal failure in the long run. On the other hand, it is important not to over-diagnose UTIs because we know that overuse of antibiotics increases costs, side effects and leads to antibiotic resistance. The first principles questions very much apply here: who to screen, how to screen, and what to do with the screen results. There are risks associated with not having a standardized approach to diagnosing pediatric UTIs. In this EM Cases main episode podcast with Dr. Olivia Ostrow and Dr. Michelle Science we discuss an approach to diagnosing pediatric UTIs whilst revealing some common pediatric UTI myths and misperceptions.... Podcast production, sound design & editing by Anton Helman. Additional editing by Sucheta Sinha. Written Summary and blog post by Lorraine Lau edited by Anton Helman April, 2019 Cite this podcast as: Helman, A. Ostrow, O. Science, M. Pediatric UTI Myths and Misperceptions. Emergency Medicine Cases. April, 2019. https://emergencymedicinecases.com/pediatric-uti-myths-and-misperceptions. Accessed [date] Pediatric UTI over-testing, over-diagnosing and over-treating There is substantial overlap between a true urinary tract infection (UTI) and asymptomatic bacteriuria leading to over-diagnosis and treatment in otherwise healthy children who presents with fever of unknown source. In a retrospective cohort study done at Hospital for Sick Children in Toronto, they looked at otherwise healthy children aged 12 weeks to 18 years who were discharged from the ED with the diagnosis of UTI [1]. Almost all were provided with an empiric antimicrobial prescription. Forty six percent of these children did not truly have a UTI. Their urine cultures were negative. In the era of Choosing Wisely, we are clearly over-testing, over-diagnosing and over-treating pediatric UTI. Urosepsis is rare in otherwise healthy, immunocompetent children. The risk of developing sepsis from a UTI has been estimated to be only 1 in 25,000 [2]. However, the risk of an untreated UTI progressing to sepsis is higher in infants compared to older children. In order to promote stewardship and reduce risk for harm, screening should be standardized integrating the pretest probability of a UTI diagnosis based on individual risk factors. Clinical presentation of pediatric UTI While the presentation in infants is very non-specific and can include vomiting, poor feeding, lethargy, failure to thrive, jaundice, or isolated fever, older children who are toilet trained are more likely to present with the classic symptoms of UTI including dysuria, frequency, hematuria, incontinence, back pain, and abdominal pain. Observational data reveal that 7% of children 2-24 months of age presenting to the ED with isolated fever without a source have a UTI [6]. Diagnostic accuracy of UTI signs and symptoms in infants The signs and symptoms of UTI in infants <24 months of age that have likelihood ratios greater than two (+LR ≥2) include [3]: * History of prior UTI * Temperature ≥40˚C * Fever >24 hrs * Suprapubic tenderness * Jaundice * Uncircumcised male Pearl: Clinically obvious source of infection decreases the likelihood ratio by half. Note that “history of prior UTI” may be a false positive, as the diagnosis may have been made on speculation with out cultures or the culture may have been a false positive. It is important to confirm that both the history of UTI was clinically compatible with the diagnosis and that the urine culture was positive.