PEDIATRICS Vol. 104 No. 5 November 1999, p. e54
ELECTRONIC ARTICLE:
Screening Tests for Urinary Tract Infection in Children: A
Meta-analysis
Received Oct 12, 1998; accepted May 17, 1999.
, §
From the * Division of Emergency Medicine, A. I. duPont
Hospital for Children, Wilmington, Delaware; the Division of
Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia,
Pennsylvania; and the § Department of Pediatrics and the Center for
Clinical Epidemiology and Biostatistics, University of Pennsylvania
School of Medicine, Philadelphia, Pennsylvania.
Objective. To review systematically and to summarize the existing literature regarding performance of rapid diagnostic tests for urinary tract infection (UTI) in children.
Design. Systematic review and meta-analysis.
Methods. 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.
Primary Results. 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 mm3 in uncentrifuged urine, the TPR was 0.77 and the FPR was 0.11.
Conclusions. 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. Key words: urinary tract infection, diagnostic tests, urinalysis, pyuria, bacteriuria, meta-analysis.
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