title: Improving the Diagnosis and Treatment of Urinary Tract Infection in Young Children in Primary Care: Results from the DUTY Prospective Diagnostic Cohort Study.
abstract: Up to 50% of urinary tract infections (UTIs) in young children are missed in primary care. Urine culture is essential for diagnosis, but urine collection is often difficult. Our aim was to derive and internally validate a 2-step clinical rule using (1) symptoms and signs to select children for urine collection; and (2) symptoms, signs, and dipstick testing to guide antibiotic treatment.
  
  
  
  We recruited acutely unwell children aged under 5 years from 233 primary care sites across England and Wales. Index tests were parent-reported symptoms, clinician-reported signs, urine dipstick results, and clinician opinion of UTI likelihood (clinical diagnosis before dipstick and culture). The reference standard was microbiologically confirmed UTI cultured from a clean-catch urine sample. We calculated sensitivity, specificity, and area under the receiver operator characteristic (AUROC) curve of coefficient-based (graded severity) and points-based (dichotomized) symptom/sign logistic regression models, and we then internally validated the AUROC using bootstrapping.
  
  
  
  Three thousand thirty-six children provided urine samples, and culture results were available for 2,740 (90%). Of these results, 60 (2.2%) were positive: the clinical diagnosis was 46.6% sensitive, with an AUROC of 0.77. Previous UTI, increasing pain/crying on passing urine, increasingly smelly urine, absence of severe cough, increasing clinician impression of severe illness, abdominal tenderness on examination, and normal findings on ear examination were associated with UTI. The validated coefficient- and points-based model AUROCs were 0.87 and 0.86, respectively, increasing to 0.90 and 0.90, respectively, by adding dipstick nitrites, leukocytes, and blood.
  
  
  
  A clinical rule based on symptoms and signs is superior to clinician diagnosis and performs well for identifying young children for noninvasive urine sampling. Dipstick results add further diagnostic value for empiric antibiotic treatment.
authors.affiliation: Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Clifton, Bristol, United Kingdom alastair.hay@bristol.ac.uk.
authors.forename: Alastair D
authors.initials: AD
authors.lastname: Hay
authors.affiliation: School of Social and Community Medicine, University of Bristol, Clifton, Bristol, United Kingdom.
authors.forename: Jonathan A C
authors.initials: JA
authors.lastname: Sterne
authors.affiliation: South East Wales Trials Unit (SEWTU), Centre for Trials Research, Cardiff University, Heath Park, Cardiff, United Kingdom.
authors.forename: Kerenza
authors.initials: K
authors.lastname: Hood
authors.affiliation: Primary Care and Population Science, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, United Kingdom.
authors.forename: Paul
authors.initials: P
authors.lastname: Little
authors.affiliation: Guys' and St Thomas' Charity Chair in Primary Care Research, NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, Department of Primary Care and Public Health Sciences, London, United Kingdom.
authors.forename: Brendan
authors.initials: B
authors.lastname: Delaney
authors.affiliation: School of Social and Community Medicine, University of Bristol, Clifton, Bristol, United Kingdom.
authors.forename: William
authors.initials: W
authors.lastname: Hollingworth
authors.affiliation: Specialist Antimicrobial Chemotherapy Unit, Public Health Wales Microbiology Cardiff, University Hospital Wales, Heath Park, Cardiff, United Kingdom.
authors.forename: Mandy
authors.initials: M
authors.lastname: Wootton
authors.affiliation: Specialist Antimicrobial Chemotherapy Unit, Public Health Wales Microbiology Cardiff, University Hospital Wales, Heath Park, Cardiff, United Kingdom.
authors.forename: Robin
authors.initials: R
authors.lastname: Howe
authors.affiliation: North Bristol NHS Trust, Southmead Hospital, Westbury-on-Trym, Bristol, United Kingdom.
authors.forename: Alasdair
authors.initials: A
authors.lastname: MacGowan
authors.affiliation: School of Social and Community Medicine, University of Bristol, Clifton, Bristol, United Kingdom.
authors.forename: Michael
authors.initials: M
authors.lastname: Lawton
authors.affiliation: School of Social and Community Medicine, University of Bristol, Clifton, Bristol, United Kingdom.
authors.forename: John
authors.initials: J
authors.lastname: Busby
authors.affiliation: South East Wales Trials Unit (SEWTU), Centre for Trials Research, Cardiff University, Heath Park, Cardiff, United Kingdom.
authors.forename: Timothy
authors.initials: T
authors.lastname: Pickles
authors.affiliation: School of Social and Community Medicine, University of Bristol, Clifton, Bristol, United Kingdom.
authors.forename: Kate
authors.initials: K
authors.lastname: Birnie
authors.affiliation: Division of Population Medicine, School of Medicine, Cardiff University, Heath Park, Cardiff, United Kingdom.
authors.forename: Kathryn
authors.initials: K
authors.lastname: O'Brien
authors.affiliation: South East Wales Trials Unit (SEWTU), Centre for Trials Research, Cardiff University, Heath Park, Cardiff, United Kingdom.
authors.forename: Cherry-Ann
authors.initials: CA
authors.lastname: Waldron
authors.affiliation: Bristol Royal Hospital for Children, University Hospitals Bristol, NHS Foundation Trust, Bristol, United Kingdom.
authors.forename: Jan
authors.initials: J
authors.lastname: Dudley
authors.affiliation: Department of Paediatrics and Child Health, University Hospital of Wales, Heath Park, Cardiff, United Kingdom.
authors.forename: Judith
authors.initials: J
authors.lastname: Van Der Voort
authors.affiliation: Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Clifton, Bristol, United Kingdom.
authors.forename: Harriet
authors.initials: H
authors.lastname: Downing
authors.affiliation: South East Wales Trials Unit (SEWTU), Centre for Trials Research, Cardiff University, Heath Park, Cardiff, United Kingdom.
authors.forename: Emma
authors.initials: E
authors.lastname: Thomas-Jones
authors.affiliation: Primary Care and Population Science, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, United Kingdom.
authors.forename: Kim
authors.initials: K
authors.lastname: Harman
authors.affiliation: South East Wales Trials Unit (SEWTU), Centre for Trials Research, Cardiff University, Heath Park, Cardiff, United Kingdom.
authors.forename: Catherine
authors.initials: C
authors.lastname: Lisles
authors.affiliation: Primary Care and Population Science, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, United Kingdom.
authors.forename: Kate
authors.initials: K
authors.lastname: Rumsby
authors.affiliation: King's College London, Division of Health and Social Care Research, Department of Primary Care and Public Health Sciences, London, United Kingdom.
authors.forename: Stevo
authors.initials: S
authors.lastname: Durbaba
authors.affiliation: NIHR CLAHRC West, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom.
authors.forename: Penny
authors.initials: P
authors.lastname: Whiting
authors.affiliation: Nuffield Department of Primary Care Health Sciences, University of Oxford, New Radcliffe House, Radcliffe Observatory Quarter, Oxford, United Kingdom, and General Practitioner, Cwm Taf University Health Board, Wales, United Kingdom.
authors.forename: Christopher C
authors.initials: CC
authors.lastname: Butler
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D011320:Primary Health Care / Q000379:methods*; D011446:Prospective Studies; D012015:Reference Standards; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D006113:United Kingdom; D016482:Urinalysis; D014552:Urinary Tract Infections / Q000175:diagnosis* / Q000628:therapy / Q000652:urine; D059349:Urine Specimen Collection / Q000379:methods*
chemical_list: D000900:Anti-Bacterial Agents
keywords: anti-bacterial agents; diagnosis; pediatrics; primary health care; urinary tract infections