Screening for urinary tract infection in infants in the emergency department: which test is best?
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).


CONCLUSIONS
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.
Shaw
K N
KN
Department of Pediatrics, Children's Hospital of Philadelphia, PA 19104, USA.
McGowan
K L
KL
Gorelick
M H
MH
Schwartz
J S
JS
D001431:Bacteriological Techniques / Q000191:economics; D003430:Cross-Sectional Studies; D004636:Emergency Service, Hospital / Q000191:economics; D005069:Evaluation Studies as Topic; D005260:Female; D006801:Humans; D007223:Infant; D007958:Leukocyte Count; D008297:Male; D011237:Predictive Value of Tests; D011446:Prospective Studies; D011934:Reagent Strips / Q000191:economics; D012680:Sensitivity and Specificity; D016482:Urinalysis / Q000191:economics / Q000379:methods*; D014552:Urinary Tract Infections / Q000175:diagnosis*; D014556:Urine / Q000737:chemistry / Q000382:microbiology
D011934:Reagent Strips