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Right arrow Emergency Medicine

PEDIATRICS Vol. 101 No. 6 June 1998, p. e1

ELECTRONIC ARTICLE:
Screening for Urinary Tract Infection in Infants in the Emergency Department: Which Test Is Best?

Received Sep 29, 1997; accepted Feb 17, 1998.

Kathy N. Shaw*, Karin L. McGowan*, Marc H. Gorelick*, and J. Sanford SchwartzDagger

From the * Department of Pediatrics, Children's Hospital of Philadelphia, Pennsylvania, and Dagger  Leonard Davis Institute, University of Pennsylvania, Philadelphia, Pennsylvania.

Objective.  Comparison of rapid tests and screening strategies for detecting urinary tract infection (UTI) in infants.

Methods.  Cross-sectional study conducted in an urban tertiary care children's hospital emergency department and clinical laboratories of 3873 infants <2 years of age who had a urine culture obtained in the emergency department by urethral catheterization; results of urine dipstick tests for leukocyte esterase or nitrites, enhanced urinalysis (UA) (urine white blood cell count/mm3 plus Gram stain), Gram stain alone, and dipstick plus microscopic UA (white blood cells and bacteria per high-powered field) compared with urine culture results (positive urine results defined as >= 10 colony-forming units per milliliter of urinary tract pathogen) for each sample. Cost comparison of 1) dipstick plus culture of all urine specimens versus 2) cell count ± Gram stain of urine, culture only those with positive results.

Results.  The enhanced UA was most sensitive at detecting UTI (94%; 95% confidence interval: 83,99), but had more false-positive results (16%) than the urine dipstick or Gram stain (3%). The most cost-effective strategy was to perform cultures on all infants and begin presumptive treatment on those whose dipstick had at least moderate (+2) leukocyte esterase or positive nitrite at a cost of $3.70 per child. With this strategy, all infants with UTI were detected. If the enhanced UA was used to screen for when to send the urine for culture, 82% of cultures would be eliminated, but 4% to 6% of infants with UTI would be missed and the cost would be higher ($6.66 per child).

Conclusion.  No rapid test can detect all infants with UTI. Physicians should send urine for culture from all infants and begin presumptive treatment only on those with a significantly positive dipstick result. The enhanced UA is most sensitive for detecting UTI, but is less specific and more costly, and should be reserved for the neonate for whom a UTI should not be missed at first visit.

Key words: urinalysis, Gram stain, dipstick, UTI, rapid screening, febrile infants.