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American Academy of Pediatrics
Article

Pyuria and Urine Concentration for Identifying Urinary Tract Infection in Young Children

Shahid Nadeem, Mohamed Badawy, Oluwaseun K. Oke, Laura M. Filkins, Jason Y. Park and Halim M. Hennes
Pediatrics February 2021, 147 (2) e2020014068; DOI: https://doi.org/10.1542/peds.2020-014068
Shahid Nadeem
aDivision of Emergency Medicine, Department of Pediatrics and
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Mohamed Badawy
aDivision of Emergency Medicine, Department of Pediatrics and
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Oluwaseun K. Oke
bChildren’s Health, Dallas, Texas
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Laura M. Filkins
cDepartment of Pathology, The University of Texas Southwestern Medical Center, Dallas, Texas; and
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Jason Y. Park
cDepartment of Pathology, The University of Texas Southwestern Medical Center, Dallas, Texas; and
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Halim M. Hennes
aDivision of Emergency Medicine, Department of Pediatrics and
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Abstract

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OBJECTIVES: Accuracy of pyuria for urinary tract infection (UTI) varies with urine concentration. Our objective of this study was to determine the optimal white blood cell (WBC) cutoff for UTI in young children at different urine concentrations as measured by urine specific gravity.

METHODS: Retrospective cross-sectional study of children <24 months of age evaluated in the emergency department for suspected UTI with paired urinalysis and urine culture during a 6-year period. The primary outcome was positive urine culture result as described in the American Academy of Pediatrics clinical practice guideline culture thresholds. Test characteristics for microscopic pyuria cut points and positive leukocyte esterase (LE) were calculated across 3 urine specific gravity groups: low <1.011, moderate 1.011 to 1.020, and high >1.020.

RESULTS: Of the total 24 171 patients analyzed, urine culture result was positive in 2003 (8.3%). Urine was obtained by transurethral in-and-out catheterization in 97.9%. Optimal WBC cutoffs per high-power field (HPF) were 3 (positive likelihood ratio [LR+] 10.5; negative likelihood ratio [LR−] 0.12) at low, 6 (LR+ 12; LR− 0.14) at moderate, and 8 (LR+ 11.1; LR− 0.35) at high urine concentrations. Likelihood ratios for small positive LE from low to high urine concentrations (LR+ 25.2, LR− 0.12; LR+ 33.1, LR− 0.15; LR+ 37.6, LR− 0.41) remained excellent.

CONCLUSIONS: Optimal pyuria cut point in predicting positive urine culture results changes with urine concentration in young children. Pyuria thresholds of 3 WBCs per HPF at low urine concentrations whereas 8 WBCs per HPF at high urine concentrations have optimal predictive value for UTI. Positive LE is a strong predictor of UTI regardless of urine concentration.

  • Accepted November 18, 2020.
  • Copyright © 2021 by the American Academy of Pediatrics

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Pediatrics
Vol. 147, Issue 2
1 Feb 2021
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Pyuria and Urine Concentration for Identifying Urinary Tract Infection in Young Children
Shahid Nadeem, Mohamed Badawy, Oluwaseun K. Oke, Laura M. Filkins, Jason Y. Park, Halim M. Hennes
Pediatrics Feb 2021, 147 (2) e2020014068; DOI: 10.1542/peds.2020-014068

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Pyuria and Urine Concentration for Identifying Urinary Tract Infection in Young Children
Shahid Nadeem, Mohamed Badawy, Oluwaseun K. Oke, Laura M. Filkins, Jason Y. Park, Halim M. Hennes
Pediatrics Feb 2021, 147 (2) e2020014068; DOI: 10.1542/peds.2020-014068
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