Neonatal Jaundice and Urinary Tract Infections
M. J. Maisels, MB, BChThomas B. Newman, MD, MPH
William Beaumont Hospital, Royal Oak, MI 48073, USA
Departments of Epidemiology and Biostatistics and, Pediatrics, School of Medicine, University of California, San Francisco, San Francisco, CA 94143, USA
To the Editor.—
Garcia and Nager1 did urethral catheterizations and urine cultures on 160 asymptomatic jaundiced infants <8 weeks old who presented to their emergency department. They found positive cultures (>10 000 colony-forming units/mL) in 7.5% of the infants: 0 of 4 circumcised boys, 9 of 94 uncircumcised boys, and 3 of 62 girls. Half of the infants with bacteriuria had negative urinalyses. Based on this information, they recommend that "testing for a urinary tract infection (UTI) be included as part of the evaluation in asymptomatic, jaundiced infants presenting to the emergency department." We disagree.
What brought these asymptomatic infants to the emergency department? It is easy to understand why jaundice appearing in a 32-day-old or 42-day-old infant (listed in their Table 2) would be brought to medical attention, but why would a 6-day-old infant with a bilirubin of 9.5 mg/dL (their case 2) come to an emergency department? Clearly those who are jaundiced in the first week and those who first manifest jaundice after 1 to 2 weeks or have conjugated hyperbilirubinemia are different populations and should be analyzed separately. Infants with the onset of jaundice after the first week and formula-fed infants who are jaundiced beyond a week should be evaluated for a pathologic cause, but most infants with jaundice appearing in the first week and almost all breastfed infants with persistent jaundice are normal. If urine cultures are positive in these last 2 groups, the infants are better labeled as having bacteriuria, rather than a UTI. Whether there is any benefit to detection and treatment of bacteriuria in these infants is not known. Even infants in this age group with apparent UTI (ie, bacteriuria and fever) generally recover without treatment.2
If these infants were otherwise asymptomatic but were brought to the emergency department only because they were jaundiced, then it is not clear why they should be treated differently from other asymptomatic jaundiced infants. But in the first 2 weeks after birth more than two thirds of normal infants are jaundiced. This means that we could be catheterizing the urethras of about 2.4 million infants a year who are minding their own business but have the misfortune to be jaundiced. This evaluation is expensive, invasive, may cause UTI,3 and may lead to false-positive results, especially in a setting of low prior probability of UTI.
Finally, the study findings cannot be generalized to circumcised boys, who are at much lower risk of UTI than uncircumcised boys or girls. In circumcised boys, the prior probability of UTI is even lower and the likelihood of false-positives is greater. Before recommending that we screen jaundiced infants for bacteriuria, we need much better data documenting that this procedure is indicated and that the infants will derive some benefit from it.
REFERENCES
- Garcia FJ, Nager AL. Jaundice as an early diagnostic sign of urinary tract infection in infancy.
Pediatrics.2002; 109
:846
–851
[Abstract/Free Full Text] - Newman TB, Bernzweig JA, Takayama JI, Finch SA, Wasserman RC, Pantell RH. Urine testing and urinary tract infections in febrile infants seen in office settings: the Pediatric Research in Office Settings’ Febrile Infant Study.
Arch Pediatr Adolesc Med.2002; 156
:44
–54
[Abstract/Free Full Text] - Lohr JA, Downs SM, Dudley S, Donowitz LG. Hospital-acquired urinary tract infections in the pediatric patient: a prospective study. Pediatr Infect Dis J.1994; 13 :8 –12[Web of Science][Medline]
Francisco J. Garcia, MD
Alan L. Nager, MD
Kapiolani Medical Center for Women and Children, Division of Emergency Medicine, Honolulu, HI 96826, USA
Childrens Hospital Los Angeles, Division of Emergency and Transport Medicine, Los Angeles, CA 90027, USA
In Reply.—
We appreciate the correspondents’ interest and comments on our article. We agree with Drs Maisels and Newman that the study findings cannot be generalized to circumcised boys. As we pointed out in the limitations of the study, the majority of infants were not circumcised; therefore, we cannot draw conclusions regarding circumcision and the incidence of urinary tract infections (UTIs) in this age group.1
Drs Maisels and Newman asked: "What brought these asymptomatic infants to the emergency department?" The study was conducted at a children’s hospital emergency department of a large metropolitan area, which at times serves as the initial point of contact for patients with or without a primary care provider. Parents independently seek care for a variety of medical complaints such as jaundice. The aim of our study was to look for associated factors that were suggestive of the presence of a UTI in all jaundiced infants. We found that infants with the reported onset of jaundice after 8 days of age, when physiologic jaundice is expected to have improved or resolved, had a higher incidence of UTIs.1 Although not statistically significant, a history of worsening jaundice, as reported by the parents, was more commonly observed in patients with positive urine cultures.1
We disagree with Drs Maisels and Newman’s point that most of the infants have bacteriuria rather than UTI. Our observation, that the incidence of a UTI in asymptomatic, jaundiced infants was approximately the same as febrile infants <8 weeks of age, suggests that we may be identifying infants with a UTI before signs and symptoms become evident. In separate studies, Krober,2 Crain,3 Hoberman,4,5 and Ginsburg6 have reported the prevalence of UTI between 5% and 11% among febrile infants <8 weeks of age. We do not consider our positive urine cultures to reflect incidental asymptomatic bacteriuria for several reasons. First, our incidence of 7.5% was substantially higher than the reported 0.5% to 1% by other studies in symptom-free infants.7–10 Second, the incidence of urinary tract abnormalities that we detected is similar to that described in previous studies (49%),11 supporting the fact that infants with urinary tract abnormalities are predisposed to a UTI. Finally, the true test of asymptomatic bacteriuria would be to withhold antibiotics and observe for clinical signs and symptoms of infection. Ethically, not treating a "positive urine culture" in infants <8 weeks of age to test this hypothesis was not felt to be reasonable or risk-free. Drs Maisels and Newman point out that based on the Pediatric Research in Office Settings’ Febrile Infant Study, "even infants in this age group with apparent UTI (ie, bacteremia and fever) generally recover without treatment."12 However, the study was performed at private physicians’ offices and does not represent the same patient population. Moreover, the study found that 10% of infants <8 weeks of age had a UTI.12 The study does not report how many patients with a UTI cleared the urine without antibiotic treatment. In addition, 10% of those with a UTI had bacteremia caused by the same organism that was found in their urine.12
Finally, Drs Maisels and Newman point out "that we will be catheterizing the urethras of about 2.4 million infants a year who are minding their own business but have the misfortune to be jaundiced." This is an inaccurate conclusion not demonstrated in our study. We stated very clearly in the limitations and conclusion of our study, "Given the fact that our study was conducted solely in the emergency department, the results obtained can not be generalized to patients in other outpatient settings" until additional studies are performed. At this point, we suggest that testing for a UTI be part of the diagnostic evaluation of asymptomatic, jaundiced infants presenting to the emergency department only.
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REFERENCES
- Garcia FJ, Nager AL. Jaundice as an early diagnostic sign of urinary tract infection in infancy. Pediatrics.2002; 109 :846 –851
- Krober MS, Bass JW, Powerll JM, Smith FR, Seto DS. Bacterial and viral pathogens causing fever in infants less than 3 months old.
Am J Dis Child.1985; 139
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[Abstract/Free Full Text] - Crain EF, Gershel JC. Urinary tract infections in febrile infants younger than 8 weeks of age.
Pediatrics.1990; 86
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[Abstract/Free Full Text] - Hoberman A, Chao HP, Keller DM, Hickey R, Davis H, Ellis D. Prevalence of urinary tract infection in febrile infants. J Pediatr.1993; 123 :17 –23[CrossRef][Web of Science][Medline]
- Hoberman A, Wald ER. Urinary tract infections in young febrile children. Pediatr Infect Dis J.1997; 16 :1:11 –17
- Ginsburg CM, McCracken GH. Urinary tract infections in young infants.
Pediatrics.1982; 69
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[Abstract/Free Full Text] - Abbott GD. Neonatal bacteriuria: a prospective study of 1460 infants. BMJ.1972; 1 :267 –269
- Edelman CM, Ogwo JE, Fine BP, Martinez AB. The prevalence of bacteriuria in full-term and premature newborn infants. J Pediatr.1973; 82 :125 –132[CrossRef][Web of Science][Medline]
- Drew JH, Acton CM. Radiological findings in newborn infants with urinary infection.
Arch Dis Child.1976; 51
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[Abstract/Free Full Text] - Wettergren B, Jodal U, Jonasson G. Epidemiology of bacteriuria during the first year of life. Acta Paediatr Scand.1985; 74 :925 –933[Web of Science][Medline]
- Goldman M, Lahat E, Strauss S, et al. Imaging after urinary tract infection in male neonates.
Pediatrics.2000; 105
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[Abstract/Free Full Text] - Newman TB, Berzweig JA, Takayama JI, Finch SA, Wasserman RC, Pantell RH. Urine testing and urinary tract infections in febrile infants seen in office settings: the Pediatric Research in Office Settings’ Febrile Infant Study. Arch Pediatr Adolesc Med.2002; 156 :44 –54
PEDIATRICS (ISSN 1098-4275). ©2003 by the American Academy of Pediatrics
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