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Urine Testing and Urinary Tract Infections in Febrile Infants Seen in Office Settings
The Pediatric Research in Office Settings' Febrile Infant Study
Thomas B. Newman, MD, MPH;
Jane A. Bernzweig, PhD;
John I. Takayama, MD, MPH;
Stacia A. Finch, MA;
Richard C. Wasserman, MD, MPH;
Robert H. Pantell, MD
Arch Pediatr Adolesc Med. 2002;156:44-54.
ABSTRACT
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Objective To determine the predictors and results of urine testing of young febrile
infants seen in office settings.
Design Prospective cohort study.
Setting Offices of 573 pediatric practitioners from 219 practices in the American
Academy of Pediatrics Pediatric Research in Office Settings' research network.
Subjects A total of 3066 infants 3 months or younger with temperatures of 38°C
or higher were evaluated and treated according to the judgment of their practitioners.
Main Outcome Measures Urine testing results, early and late urinary tract infections (UTIs),
and UTIs with bacteremia.
Results Fifty-four percent of the infants initially had urine tested, of whom
10% had a UTI. The height of the fever was associated with urine testing and
a UTI among those tested (adjusted odds ratio per degree Celsius, 2.2 for
both). Younger age, ill appearance, and lack of a fever source were associated
with urine testing but not with a UTI, whereas lack of circumcision (adjusted
odds ratio, 11.6), female sex (adjusted odds ratio, 5.4), and longer duration
of fever (adjusted odds ratio, 1.8 for fever lasting  24 hours) were not
associated with urine testing but were associated with a UTI. Bacteremia accompanied
the UTI in 10% of the patients, including 17% of those younger than 1 month.
Among 807 infants not initially tested or treated with antibiotics, only 2
had a subsequent documented UTI; both did well.
Conclusions Practitioners order urine tests selectively, focusing on younger and
more ill-appearing infants and on those without an apparent fever source.
Such selective urine testing, with close follow-up, was associated with few
late UTIs in this large study. Urine testing should focus particularly on
uncircumcised boys, girls, the youngest and sickest infants, and those with
persistent fever.
INTRODUCTION
URINARY TRACT infection (UTI) is the most commonly identified serious
bacterial infection among febrile infants younger than 2 to 3 months, occurring
in 3% to 10% of such infants.1-6
Because the signs and symptoms of UTI in this age group are nonspecific, urinalysis
and urine culture generally are recommended to determine the source of the
fever.1, 5, 7-10
Is the recommendation for universal urine testing of febrile infants younger
than 3 months being followed by practitioners? Should it be?
The Pediatric Research in Office Settings' (PROS) Febrile Infant Study
was a prospective study of 3066 febrile infants 3 months or younger who were
seen by pediatric practitioners in their offices. Unlike previous large series
of febrile infants in this age group, urine testing was done at the discretion
of the study practitioners rather than routinely. This provided the opportunity
to determine the frequency of urine testing and the prevalence of UTIs among
those tested. In addition, the predictors of UTI could be compared with the
factors associated with urine testing. Because many febrile infants were managed
without initial urine testing, we could also investigate how often lack of
initial testing resulted in subsequent problems. This report from the PROS
Febrile Infant Study addresses the following questions: (1) What are the frequency
and clinical predictors of urine testing of young febrile infants seen in
office settings? (2) What are the frequency and clinical predictors of UTI
and of UTI with bacteremia among those tested? (3) What are the frequencies
of late diagnosis of UTI and of UTI with bacteremia among patients who did
not have an initial urine specimen tested?
SUBJECTS AND METHODS
PROS NETWORK AND PRACTITIONERS
This prospective cohort study was conducted in practices participating
in the American Academy of Pediatrics' practice-based research network, PROS.11 The PROS network currently includes more than 1600
practitioners from 50 states, Puerto Rico, and Canada; 573 practitioners from
219 practices enrolled eligible patients in this study between February 28,
1995, and April 25, 1998. Pediatric Research in Office Settings' practitioners
for this study came from 44 states, the District of Columbia, and Puerto Rico.
When compared with American Academy of Pediatrics' members who listed patient
care as their primary activity in a 1995 American Academy of Pediatrics' periodic
survey,12 PROS practitioners were comparable
for age, sex, and practice arrangement, but were less likely to practice in
inner-city locations (7% vs 12%).
STUDY SUBJECTS
Infants were eligible for inclusion in the study if they (1) were no
older than 3 months; (2) had axillary, rectal, or tympanic temperatures of
at least 38°C in the office or in the previous 24 hours at home; and (3)
were initially examined by a PROS practitioner. Because practitioners ordered
diagnostic tests and treatments according to their usual clinical judgment,
informed consent from the subjects was not required. The study was approved
by the University of California, San Francisco, Committee on Human Research.
PREDICTOR VARIABLES
Clinical and Demographic Data
The PROS practitioners and their office staffs recorded clinical and
demographic data on standard forms. The study protocol required that the initial
physical examination results, diagnostic impression, and assessment of overall
severity of illness be recorded before the results of any laboratory tests
were available.
The temperature variable used for these analyses was created by adding
0.5°C to axillary temperatures, then taking the higher of the temperatures
taken in the office or at home.13 Results for
many components of the history and physical examination (eg, duration of fever,
general appearance, degree of respiratory distress, and quality of cry) could
be indicated by checking appropriate boxes on the data collection form. Practitioners
recorded other significant findings as free text; these were grouped and coded
by the study staff without knowledge of the child's ultimate diagnosis or
outcome.
Laboratory Data
To facilitate comparisons of urinalysis results across practices, all
practices were supplied with dipsticks (Ames-Multistix; Miles, Inc, Elkhart,
Ind), which include tests for leukocyte esterase and nitrite. All other laboratory
tests, including urine cultures, were done in the laboratories normally used
by the practitioners.
Missing Data
For the most important data items (initial temperature, age, sex, and
final outcome), most missing, ambiguous, or suspicious data items were obtained
or verified through inquiries to individual PROS practitioners. The data collection
form included the dates of urine cultures but not of urinalyses. We considered
urine testing to have been done on the date of the urine culture, if available.
For the 240 infants for whom no urine culture date was provided (14% of the
1775 whose urine was tested), we used the date of the initial examination.
Many other items existed on the data collection form as boxes to check if
the finding was present; for these items, we assumed the finding was absent
if the box was not checked. For categorical variables describing aspects of
the infant's overall appearance (eg, level of alertness), we dichotomized
the variables and grouped infants with missing data (about 1%) with those
who did not have worrisome values. We also coded the variable regarding ill
family members as none in the 160 infants (5% of the total 3066 infants) in
whom it was missing. For other variables, missing values were either explicitly
grouped with other values or analyzed separately.
OUTCOME VARIABLES
Laboratory Data
We considered urine testing to have been done if results of either a
urinalysis or a urine culture were recorded. We chose to look at predictors
of urine testing rather than predictors of urine culture, because a major
obstacle to urine culture is obtaining the sample and because some of the
decisions to perform urine cultures might have been made based on the results
of the urinalysis.
The diagnosis of a UTI was based on urine culture results; a positive
urinalysis result was not required. A pediatric infectious disease consultant
who was blinded to data on individual subjects classified organisms identified
in the urine as pathogenic, sometimes pathogenic, and nonpathogenic. Organisms
that were either pathogenic or sometimes pathogenic were considered pathogenic
for this study. Infants whose urine was obtained by suprapubic aspiration
were considered to have a UTI if the urine culture grew at least 100 colony-forming
units per milliliter of 1 or more pathogenic organisms. Infants whose urine
was obtained by urethral catheterization were considered to have a UTI if
urine cultures grew at least 20 000 colony-forming units per milliliter
of a single pathogenic organism. For bag- and clean-voided specimens, at least
100 000 colony-forming units per milliliter of a single pathogenic organism
were required. Three additional infants were considered to have a UTI: 1 whose
urine culture was lost in the laboratory, but who had pyuria and was diagnosed
as having a renal abscess, and 2 whose urine colony counts were missing but
who had Escherichia coli isolated from blood and
urine.
Follow-up
Practitioners followed up all infants and recorded each interaction
until the infants had recovered from the acute illness. No follow-up data
could be obtained for 119 (4%) of the 3066 infants. Compared with infants
for whom follow-up data were available, these infants were similar in age
(average, 3 days older; P = .22), but their mean
temperature was 0.1°C lower (P = .003) and they
were more likely to have a diagnosis of upper respiratory tract infection
(49% vs 34%; P = .001).
STATISTICAL ANALYSES
We used a spreadsheet program (Excel, version 5.0; Microsoft Corporation,
Redmond, Wash) to calculate odds ratios and statistical software (Stata, releases
5 and 6; Stata Corp, College Station, Tex) for all other statistical analyses.
For analyses of predictors of urine testing and of UTI, we considered only
variables available and urinalyses and urine cultures done on the date of
the initial examination. We began with simple bivariate analyses relating
these outcomes to clinical and demographic predictors (in their original form)
to screen for associations that might be missed if predictor variables were
dichotomized. We then dichotomized variables as appropriate and entered significant
predictors based on bivariate analyses into backward stepwise multiple logistic
regression analyses to identify significant independent predictors of urine
testing and of UTI. All logistic regression analyses were done using the "cluster"
option in the statistical software (Stata) to account for the nonindependence
of infants enrolled by the same practitioner. Goodness of fit of the logistic
model was assessed using the method of Hosmer-Lemeshow with 10 groups.14 Discrimination was assessed using the c statistic, equal to the area under the receiver-operating characteristic
curve.14
For multiple logistic analyses in which the outcome variable was initial
urine testing, because of the many infants whose urine was tested, we included
only variables significant at P = .03 to avoid identifying
too many statistically but not clinically significant predictors. For analyses
in which the outcome variable was a UTI, because of the much smaller sample
size (of UTIs), we used P = .05. In addition to variables
associated with a UTI at P<.05 on bivariate analyses,
we also included race, ethnicity, and all variables that were significantly
associated with urine testing in the logistic analyses previously described.
The multiple logistic model provides a predicted probability of a UTI
for each infant, based on that infant's values for the various variables that
were predictive of a UTI.15 We used these predicted
probabilities of UTI to estimate the number of infants whose urine was not
tested at the first visit who would be expected to have a UTI if their urine
were cultured initially. For these analyses, we restricted attention to infants
with complete follow-up data who were not initially treated with antibiotics.
By multiplying the average predicted probability of a UTI for these infants
by the number of infants at risk, we arrived at an approximate number of infants
expected to have a UTI at the initial visit whose UTIs were not initially
diagnosed or treated. We then determined how many infants were later diagnosed
as having a UTI, based on positive urine culture results with dates after
the initial examination date.
RESULTS
CHARACTERISTICS OF PROS PRACTITIONERS
Characteristics of the 573 PROS practitioners who enrolled 1 or more
infants in the study are shown in Table
1. Most were physicians, white, and in group practice. Slightly
more than half were men and younger than 45 years. The median number of infants
enrolled per practitioner was 3 (range, 1-78 infants).
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Table 1. Characteristics of the 573 PROS Practitioners Participating
in the Febrile Infant Study*
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URINE TESTING
Pediatric Research in Office Settings' practitioners obtained a urinalysis
on 1652 (54%) of the 3066 infants and urine cultures on 1608 (52%) of the
infants. At least 1 of the 2 tests was performed on 1775 infants (58%). In
1666 infants (54% of all infants and 94% of those tested), either a urinalysis
or a urine culture was performed on the day the infant was first examined.
Of the cultured urine specimens, 70% were obtained by urethral catheterization,
25% by urine bag, 3% by suprapubic aspiration, and 2% by clean catch.
Numerous demographic and clinical predictors were statistically significantly
associated with urine testing on the day of the initial visit (Table 2). The highest rate of initial urine testing (44 [88%] of
50 patients) occurred among those whose initial appearance was "very ill";
all 6 of the very ill–appearing infants whose urine was not tested had
respiratory distress. On multiple logistic regression analyses, the strongest
independent predictors of testing were younger age, higher fever, initial
ill appearance, and absence of findings suggesting an alternative source for
the fever, such as otitis media, upper respiratory tract symptoms, or ill
family members (Table 3). Several
potential signs of serious illness, such as sleepiness, inconsolability, and
not smiling, were associated with increased urine testing, but vomiting was
not. Overall, the discrimination of the logistic model for urine testing was
good (c = 0.77), with a good fit (Hosmer-Lemeshow  28 = 12.7; P = .12).
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Table 2. Selected Clinical and Demographic Predictors of Urine Testing
on the Day of the Initial Examination and of a UTI Among Those Tested*
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Table 3. Multivariate Predictors of Urine Testing on the Date of the
Initial Visit
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URINARY TRACT INFECTION
One hundred sixty-seven infants (5% of the entire cohort and 9% of those
ever tested) met our criteria for a UTI. Of these 167 infants, 161 underwent
urine testing on the initial examination date; the UTI rate among those initially
tested was 10% (161/1666). The infections were predominantly due to E coli (Table 4).
Bivariate analyses of predictors of a UTI on the day of the initial examination
(Table 2) and results of stepwise
multiple logistic regression (Table 5) demonstrate considerable overlap between predictors of urine testing and predictors
of a UTI among those tested. The ability of the logistic model to predict
a UTI was similar to the ability to predict testing (c
= 0.77); the goodness of fit was excellent (Hosmer-Lemeshow 28 = 4.0, P = .85). The height of the fever
was a strong predictor of urine testing and a UTI. A history of ill family
members or physical findings suggesting a different source for the fever,
especially respiratory distress, were associated with less testing and a lower
risk of a UTI.
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Table 4. Causative Organisms for UTI and UTI With Bacteremia*
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Table 5. Multivariate Predictors of UTI Among Infants Whose Urine Was
Tested on the Date of the Initial Visit*
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On the other hand, several variables associated with testing were not
associated with a UTI. The infant's age and overall appearance were strong
predictors of urine testing but poor predictors of a UTI. In fact, infants
with more findings generally associated with serious illness were less likely
to have a UTI. On multivariate analysis, the finding that the infant was inconsolable
was associated with a statistically significant decrease in the odds of having
a UTI (Table 5).
The predictors of a UTI that were not predictors of testing are of particular
interest. The strongest of these were female sex and lack of circumcision.
In multiple logistic regression analyses with circumcised boys as the comparison
group, the odds of a UTI were 5.4 times higher in girls and 11.6 times higher
in uncircumcised boys. However, circumcision status (P
= .06) and sex (P = .20) were not significantly associate
with urine testing. Infants whose fever had lasted more than 24 hours had
an 80% higher odds of having a UTI, but were no more likely to be tested.
Hispanic infants were less likely to have a UTI on multivariate analysis (adjusted
odds ratio, 0.5), but no less likely to be tested. Because Hispanic boys were
much more likely to be uncircumcised (66% compared with 12% in non-Hispanic
white boys), their decreased risk of a UTI was not apparent until confounding
by circumcision status was controlled. A lower risk for African Americans
was not statistically significant in either bivariate (P = .22) or multivariate (P = .10) analyses;
if included in the final logistic model, the adjusted odds ratio for African
Americans was 0.54 (95% confidence interval [CI], 0.3-1.1).
UTI WITH BACTEREMIA OR MENINGITIS
Of the 167 infants with a UTI, 17 (10%) had bacteremia caused by the
same organism that was isolated from the urine (Table 6). The proportion of UTIs accompanied by bacteremia was similar
in uncircumcised boys, girls, and circumcised boys. The risk of bacteremia
with a UTI seemed to decline with age, but this difference did not reach statistical
significance. Although about half of the infants with a UTI and bacteremia
looked only minimally ill and about half had temperatures lower than 39°C,
all but 3 had a positive urinalysis result (the dipstick was positive for
leukocyte esterase or there were >10 white blood cells per high-power field)
and all but 2 were initially hospitalized. Rates of bacteremia were similar
among infants whose diagnoses of UTI were based on urine collected by bag
and by urethral catheterization. Of the 167 infants with a UTI, 98 (59%) underwent
a lumbar puncture. None had bacterial meningitis. Three were diagnosed as
having viral meningitis.
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Table 6. Infants With a UTI and Bacteremia*
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DIAGNOSES OF UTI IN INFANTS NOT INITIALLY TESTED
We applied the logistic model derived from infants whose urine was tested
on the date of their initial examination to the remainder of the infants to
estimate how many additional UTIs might be observed if all infants were tested
on the first day (Figure 1). The
logistic model allows us to take into account that infants not initially tested
were at lower risk of a UTI than those tested, as illustrated by their lower
average temperature, 38.5°C compared with 38.8°C. Based on their temperature,
sex, circumcision status, and other variables, the predicted probability of
a UTI in the group that was not tested was about 8%. This means that if the
model is not missing any key variables, about 8% of the 1400 infants not tested
on day 1 (111 infants) would have been diagnosed as having a UTI had they
been tested.
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Predicted and observed urinary tract infections (UTIs) by initial
urine testing, follow-up, and antibiotic treatment. The predicted probability
of a UTI in each box (P[UTI]) is derived from the logistic model based on
infants whose urine was tested on the day of their first visit. Avg indicates
average; Temp, temperature.
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Our study design permitted us to investigate the natural history of
UTIs in low-risk infants (those judged by their practitioners to be at sufficiently
low risk not to need a urine test or antibiotics on day 1). There were 807
infants not initially tested, not unavailable for follow-up, and not initially
treated with antibiotics. In this group, the average predicted probability
of a UTI was 7.6%, suggesting that about 61 of the 807 infants would have
had positive urine culture results at their initial visit, had a culture been
performed. Only 2 (0.25%) of the 807 untested and untreated infants (95% CI,
0.03%-0.90%) subsequently were diagnosed as having a UTI, based on cultures
done on the day following the initial examination. Neither had bacteremia,
and both were treated and recovered uneventfully.
COMMENT
In this study, we found that office-based pediatric practitioners obtained
urine for urinalysis or culture in about 58% of febrile infants aged 3 months
and younger, most often on the date of the initial examination. This contrasts
with many published recommendations1, 7-10
that suggest urine testing in all febrile infants this young. However, it
is consistent with results from other studies16-19
that indicate that many practitioners order fewer tests in febrile infants
than recommended in published guidelines.
In selecting which infants to test, practitioners seemed to rely on
2 groups of factors: those associated with the potential severity of illness,
such as age and ill appearance, and those associated with the probability
of a UTI, such as a medical history or physical findings suggesting another
cause for the fever. This is consistent with a survey17
of Utah primary care pediatric practitioners, in which 91% responded that
they would order a urinalysis for a 3-week-old infant with a temperature of
38.5°C, but only 24% would order a urinalysis for a 2-month-old infant
with a temperature of 38.7°C and bilateral otitis media. Infants with
respiratory distress often did not undergo urine testing; this is consistent
with reports20-21 that the yield
of urine cultures in infants with bronchiolitis is low.
We documented that 10% (95% CI, 8%-11%) of those whose urine was initially
tested had a UTI, including 19% of uncircumcised boys and 13% of girls. Ten
percent of those with a UTI had bacteremia caused by the same organism that
was found in their urine. As found in previous studies,1-2,22-23
almost all UTIs were due to E coli or other enteric
gram-negative rods. The rate of UTI among those whose urine was cultured in
the present study is higher than the 3% to 7% reported in most previous studies,1-3,5-6
in which all febrile infants had their urine cultured. Some of this discrepancy
is because of selective urine testing in the present study. As shown in Figure 1, those whose urine was not initially
tested had a lower projected risk of a UTI (8%) than those whose urine was
initially tested (10%) because of differences like lower temperatures. The
projected UTI rate for the entire cohort of infants, 9%, is closer to results
from other studies1-3,5-6
and is probably still a bit inflated because of residual selection bias by
predictors of UTI that were not included in our logistic model. On the other
hand, the method of urine collection cannot explain the observed higher rates.
Only 22% of the UTIs in the present study were diagnosed based on bag urine
samples, and the frequency of UTIs among infants whose urine was obtained
by bag was the same as the frequency in those whose urine was obtained by
urethral catheterization. This finding suggests that bag urine collection,
although not recommended in guidelines, performs reasonably well in practice
settings and may be preferable to no urine collection at all.
The bacteremia rates among infants with a UTI in the present study,
ranging from 6% in 2- to 3-month-old infants to 17% in infants younger than
1 month, are consistent with previous studies24-27
that found a much higher risk of bacteremia among the youngest infants with
UTIs. In fact, these figures underestimate the age gradient for bacteremia,
because urine and blood cultures were done more selectively in older than
in younger infants in the present study. Unlike some previous studies,25, 28 we observed no deaths and no cases
of bacterial meningitis among the infants with UTIs. However, the nearly 20%
rate of bacteremia with UTI in infants younger than 1 month suggests that
younger infants should be especially considered for urine testing.
The discrepancies between factors associated with urine testing and
those predictive of a UTI suggest strategies for improving the way practitioners
select infants for urine testing. In particular, female sex and lack of circumcision
were strongly associated with a UTI, but not with urine testing. The nearly
12-fold increase in the odds of a UTI in uncircumcised boys in the present
study is similar to that observed in other studies.29-30
The risk of bacteremia in uncircumcised boys with a UTI was similar to that
of girls and circumcised boys, suggesting that these UTIs are real, as opposed
to an artifact of difficulty obtaining clean urine specimens for culture in
uncircumcised boys. We, therefore, recommend urine testing in most uncircumcised
boys.
Two additional discrepancies are worth noting. Infants whose fever was
present for 24 hours or longer had an 80% higher odds of a UTI than those
whose fever was of shorter duration, but were not more likely to have their
urine tested. Thus, prolonged duration of fever seems to be an indication
for urine testing. In addition, we found that after adjusting for other variables,
particularly circumcision status, Hispanic infants were at lower risk than
non-Hispanic infants, but were tested at the same rate.
The possibility that race or ethnicity might predict a UTI is supported
by previous studies31-32 of older
infants that found a significantly lower risk for UTIs among African Americans.
African American infants seemed to be at lower risk in the present study,
but the numbers were too small to be statistically significant. We are unaware
of previous studies indicating a lower risk in Hispanic infants. Thus, we
believe that, based on the present study only, it would be premature to use
a much different threshold for obtaining urine culture samples from Hispanic
infants than from infants of other ethnicities.
The variation in urine testing practices among different practitioners
allowed us to compare short-term outcomes among infants who did and did not
undergo initial urine tests. Among the 807 infants not initially tested or
treated with antibiotics, we would have expected about 61 to have had a UTI,
based on their sex, circumcision status, temperature, and other predictors
of UTIs. Yet, in only 2 infants was that diagnosis subsequently made, suggesting
that in most infants at least the acute symptoms of UTI subside spontaneously.
This conclusion is not sensitive to the accuracy of the logistic model for
predicting a UTI, because even if the risk of a UTI in those not tested were
only a third as high as our estimate (ie, 20 predicted UTIs rather than 61),
we would still conclude that the acute symptoms resolved spontaneously in
most (18 [90%] of 20) infants. Furthermore, the observed low rates of late
UTI (2/807; 95% CI, 0.03%-0.89%) and of catastrophic events because of a missed
UTI (0/807; 95% CI, 0%-0.37%) in those not initially tested or treated with
antibiotics are not dependent on the projection of the number of missed UTIs.
On the other hand, the absence of catastrophic events does not imply
the absence of harm. This study was not designed to address renal damage or
other potential late sequelae of UTIs. These might differ in frequency between
those whose UTIs were diagnosed and treated and those whose UTIs spontaneously
resolved.
Some additional limitations of the PROS Febrile Infant Study should
be addressed. By design, this study included only those young febrile infants
who had their initial clinical assessment with a PROS practitioner. Therefore,
any infants presenting or referred directly to an emergency department were
not included in the study. The frequency and outcomes of urine testing and
UTIs might differ in these infants. Similarly, some eligible infants who presented
to PROS practitioners were not enrolled. However, whether such infants were
more, equally, or less ill than infants in the study, the main conclusions
of the study would not be affected.
CONCLUSIONS
Many pediatric practitioners test the urine of young febrile infants
according to their clinical judgment rather than routinely. Although this
approach differs from usual recommendations, we found few late diagnoses of
UTIs and no cases of UTIs with bacteremia among more than 800 infants whose
urine was not initially tested. This suggests that a selective approach to
urine testing is likely to be safe in the hands of experienced practitioners
who closely follow up their patients, as was the case in the present study.
However, when using a selective approach to testing for UTIs, some factors
placing infants at high risk for a UTI, including female sex, lack of circumcision,
and longer duration of fever, should be more heavily weighted in deciding
which infants should undergo urine testing.
| What This Study Adds
It is known that 3% to 10% of young febrile infants have UTIs and that
uncircumcised boys are at highest risk. It is not known whether pediatric
practitioners follow guidelines and order urine tests for all febrile infants
or whether they order urine tests selectively. To our knowledge, no previous
studies have reported the short-term follow-up results of untreated febrile
infants whose urine was not initially tested.
We found that many pediatric practitioners ordered initial urine tests
selectively. They were more likely to test younger and sicker infants and
those with no apparent fever source, but not uncircumcised boys, girls, and
those with a fever for more than 24 hours, although these infants are at higher
risk of a UTI. Only 2 of 807 infants not initially tested or treated with
antibiotics were subsequently diagnosed as having a UTI, and both did well,
suggesting that, with close follow-up, short-term adverse outcomes from selective
urine testing are uncommon.
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AUTHOR INFORMATION
Accepted for publication September 10, 2001.
This study was supported by grant R01 HS06485 from the Agency for Health
Care Policy and Research, Rockville, Md; and grant MCJ-177022 from the Health
Resources and Services Administration Maternal and Child Health Bureau, Rockville.
This study was presented at the Pediatric Academic Societies' Meetings,
Boston, Mass, May 13, 2000.
We thank G. Mark Spitalny for helping with the data management and analyses;
Jay Tureen, MD, for infectious disease consultation; and especially the PROS
practitioners for their help.
| Participants in the Pediatric Research in
Office Settings' Febrile Infant Study
The pediatric practices or individual practitioners who enrolled subjects
in this study are listed here by American Academy of Pediatrics chapter.
Alabama, Birmingham: Drs Heilpern & Reynolds,
PC; Growing Up Pediatrics, PC; and University of Alabama.
Alaska: Anchorage Neighborhood Health Center,
Anchorage Pediatric Group, and Pediatrics (Anchorage),
and Eielson Clinic (Eielson).
Arizona: Mesa Pediatrics Professional Associates,
and Orange Grove Pediatrics, Tanque Verde Pediatrics, and Cigna HealthCare
(Tucson).
California-1: Palo Alto Medical Clinic, University
of California–San Francisco, Palo Alto Medical Foundation (Los Altos), Palo Alto Medical Clinic (Fremont),
Shasta Community Health Center (Redding), Healthy
Trails Pediatric Medical Group (Freedom), Anita Tolentino-Macaraeg,
MD (Hollister), Eureka Pediatrics (Eureka), Cantor, Giedt, & Kamachi (Salinas),
and Marin Community Clinic (Greenbrae).
California-2: Clinic Sierra Vista (Lamont), Pediatric Associates of Pasadena, Touraj Shafai, MD (Riverside), and Facey Medical Group (Canyon Country).
California-4: Edinger Medical Group, Inc (Fountain Valley) and Southern Orange County Pediatric Associates
(Lake Forest).
Colorado, Denver: Rocky Mountain Youth.
Connecticut: St Francis Pediatric Primary Care
Center (Hartford), Hemant Panchal, MD (Enfield), and Uwe Koepke, MD (Danbury).
Delaware, Newark: Pediatric Associates.
District of Columbia, Washington: George Washington
University Health Plan.
Florida: Sawgrass Pediatrics, PA (Coral Springs), Jonathan Rubin, MD, PA (Margate),
MacKoul Pediatrics (Cape Coral), SW Florida Pediatric
Network and Emilio DelValle, MD (Fort Myers), Atlantic
Coast Pediatrics (Merritt Island), Orlando Health
Care Group and Arnold Palmer Women & Children's Hospital (Orlando), Sacred Heart Pediatric Care Center (Pensacola), and Giangreco & Scarano Pediatrics (Bradenton).
Georgia: The Pediatric Center (Stone Mountain) and Children's Hospital at Memorial (Savannah).
Hawaii, Honolulu: Jeffrey Lim, MD, Melinda
Ashton, MD, and Pediatrics Department, Kapi‘olani Medical Center for
Women and Children.
Illinois: Southwest Pediatrics (Palos Park), SIU Physicians & Surgeons–Auburn, LaGrange Pediatrics
(Western Springs), Sidney Smith, MD (Carbondale), and Signature Medical Associates (Elgin).
Indiana: Georgetown Medical Care and Northpoint
Pediatrics (Indianapolis), Pediatric Advocates (Peru), George Sorrells, MD (Bedford),
Bloomington Pediatric Associates, PC, and Southern Indiana Pediatrics, LLC
(Bloomington), Lynn Ryan, MD (Lawrenceburg), Marshall County Pediatrics (Plymouth), Jeffersonville Pediatrics (Jeffersonville),
and Children's Health Care (Batesville).
Iowa: David Kelly, MD (Marshalltown), and West Des Moines Family Physicians (West Des
Moines).
Kansas: Bethel Pediatrics (Newton) and Ashley Clinic (Chanute).
Kentucky, Lexington: Michael Simon, MD.
Maine: John Salvato, MD (Waterville), and Intermed Pediatrics (Yarmouth).
Maryland: Clinical Associates, PA (Towson); Andorsky, Finkelstein and Cardin (Owings
Mills); Children's Medical Group (Cumberland);
Steven Caplan, MD, and O'Donovan & Ahluwalia, MD, PA (Baltimore); Shore Pediatrics (Easton); Drs
Wiczer, Korengold, Mayol, and D'Albora & Osha, MD, PA (Bethesda); Shady Side Medical Associates (Shady Side); The Children's Doctors (Westminster); Coleman,
Coleman, & Sachs (Rockville); and Potomac Physicians
(Severna Park).
Massachusetts: Framingham Pediatric, PC, Garden
City Pediatrics (Beverly), Burlington Pediatrics
(Burlington), Medical West Associates (Chicopee), Holyoke Pediatric Associates (Holyoke), John Mulqueen, MD (Gardner), Pediatric
Associates of Norwood (Norwood), Cape Cod Pediatrics
(Forestdale), and Winthrop Community Health Center
(Winthrop).
Michigan: Botsford Pediatrics (Farmington), H. M. Hildebrandt, MD (Ypsilanti),
Essexville Medical Clinic (Bay City), Downriver Pediatric
Associates, PC (Lincoln Park), Child Health Associates
(Ann Arbor), Pediatric & Family Care of Rochester
Hills, PC (Rochester Hills), Lee & Kim Associates
(Warren), and Orchard Pediatrics (West Bloomfield).
Minnesota, Minnetonka: South Lake Pediatrics.
Missouri: Pediatric Associates of SW Missouri
(Joplin), Children's Clinic (Springfield), and Doctor's Clinic (Carruthersville).
Montana, Stevensville: Stevensville Pediatrics.
New Hampshire: Exeter Pediatric Associates
(Exeter), Lahey-Hitchcock Clinic, Concord, Dartmouth-Hitchcock
Clinic (Lebanon), Laconia Clinic (Laconia), Pediatric & Adolescent Medicine (Kingston), and Dartmouth-Hitchcock Clinic, Keene.
New Jersey: Kids Care Pediatrics (Egg Harbor Township), Salem Road Pediatrics (Burlington), and Coventry Family Practice (Phillipsburg).
New Mexico, Albuquerque: Albuquerque Pediatric
Associates, Ltd, and University of New Mexico Hospital.
Nevada: Physician's Center West (Fallon), and Job's Peak Primary Care Specialists (Gardnerville).
New York-1: Panorama Pediatric Group, Elmwood
Pediatric Group, Park Medical Group, Edward Lewis, MD, and Genesee Health
Service (Rochester); Albany Medical College Pediatric
Group; Southern Tier Health Associates (Wayland);
Gayle Buckley, MD (Ballston Lake); Pine Street Pediatric
Associates, PC (Kingston); North Country Children's
Clinic (Watertown); and Springville Pediatrics (Springville).
New York-2: Women & Children's Health Center
(Long Island City), Gary Mirkin, MD (Great Neck), Southampton Pediatric Associates (Southampton), and Sonia Vinas, MD (Brooklyn).
New York-3, New York: Saint Vincent's Pediatric
Associates.
North Carolina: Eastover Pediatrics (Charlotte), Triangle Pediatric Center (Cary), and Peace Haven Family Health Center (Winston-Salem).
North Dakota: Medical Arts Clinic (Minot), Altru Clinic (Grand Forks), Dakota
Clinic, Ltd–Jamestown.
Ohio: Bryan Medical Group (Bryan), South Dayton Pediatrics, Inc (Dayton),
Oxford Pediatrics & Adolescents (Oxford), Pediatrics
(Portsmouth), Family Health Center (Idaho), Oberlin Clinic (Oberlin), Children's
Hospital Physicians Associates (Twinsburg), North
Central Ohio Family Care (Galion), Drs Harris &
Rhodes (Lancaster).
Oklahoma: Pediatric & Adolescent Care and
OU Pediatric Clinic (Tulsa), and Eastern Oklahoma
Medical Plaza (Poteau).
Oregon: Eugene Clinic (Eugene), North Bend Medical Center (Coos Bay).
Pennsylvania: Pennridge Pediatric Associates
(Sellersville), Praful Bhatt, MD (Lock Haven), Reading Pediatrics, Inc (Wyomissing), Children's Health Care (Allentown), Erdenheim
Pediatrics (Flourtown), Yoon-Taek Chun, MD (East Stroudsburg), Pediatric Associates of Plymouth (Norristown), Plum Pediatrics (Pittsburgh), Einstein Community Health Associates and Pediatric Group Services
(Philadelphia), Cevallos and Moise Pediatric (Quakertown), VNA KidsCare (Bethlehem), Laurel Health Center (Blossburg).
Puerto Rico, San Juan: Edna Zayas, MD, and
Pediatric Ambulatory Clinic.
Rhode Island, Cranston: Marvin Wasser, MD.
South Carolina: Anderson Pediatric Group (Anderson), Grand Strand Pediatrics & Adolescent Medicine
(Surfside Beach), and Barnwell Pediatrics, PA (Barnwell).
Tennessee, Johnson City: Johnson City Pediatrics,
PC.
Texas: The Pediatric Clinic (Greenville), Winnsboro Pediatrics (Winnsboro),
Pediatrics (Sherman), Sarah Helfand, MD, and White
Rock Pediatrics, PA (Dallas), Cleveland Pediatric
& Adolescent Clinic (Cleveland), University of
Texas Health Center at Tyler–Pediatrics, Pediatric Clinic (Mineral Wells), UNTHSC at Fort Worth Pediatric Clinic, and Family Medical
Center (Big Spring).
Utah: Gordon Glade, MD, and John Weipert, MD
(American Fork); Mountain View Pediatrics (Sandy); and Granger Medical Center, Willow Creek Pediatrics,
and University of Utah Health Sciences Center (Salt Lake
City).
Vermont: University Pediatrics (Burlington); Practitioners of Pediatric Medicine, CHP Timber Lane Pediatrics,
and Joseph Hagan, Jr, MD (South Burlington); CHP
Brattleboro Pediatrics (Brattleboro); University
Pediatrics (Williston); Rebecca Collman, MD (Colchester); Mousetrap Pediatrics (Milton); Judy Orton, MD (Bennington); and St Johnsbury
Pediatrics (St Johnsbury).
Virginia: Pediatric Associates of Richmond,
Inc; Alexandria Lakeridge Pediatrics; Drs Casey, Goldman, Lischwe, Garrett
& Kim and Pediatric Clinic (Arlington); Fishing
Bay Family Practice (Deltaville); and Stafford Pediatrics,
PC (Stafford).
Washington: Valley Children's Clinic (Renton), Rockwood Clinic (Spokane),
Yakima Valley Farm Workers Clinic (Toppenish), Paulouse
Pediatrics (Pullman), Columbia Health Center (Seattle).
West Military, Lackland Air Force Base: Department
of Pediatrics/PSP.
West Virginia: Grant Memorial Pediatrics (Petersburg), and Tess Alejo, MD (Martinsburg).
Wisconsin: Beloit Clinic SC, Gundersen Clinic
(La Crosse); Waukesha Pediatric Associates and Aurora Health Center–Waukesha
(Waukesha); and Children's Hospital of Wisconsin
Downtown Health Center (Milwaukee).
Wyoming: Jackson Pediatrics (Jackson), and Cheyenne Children's Clinic (Cheyenne).
|
|
Corresponding author and reprints: Thomas B. Newman, MD, MPH, Department
of Epidemiology and Biostatistics, University of California, San Francisco,
Campus Box 0560, San Francisco, CA 94143-0560 (e-mail: newman{at}epi.ucsf.edu).
From the Departments of Epidemiology and Biostatistics (Dr Newman),
Pediatrics (Drs Newman, Bernzweig, Takayama, and Pantell), and Family Health
Care Nursing (Dr Bernzweig), University of California, San Francisco; Pediatric
Research in Office Settings, Center for Child Health Research, American Academy
of Pediatrics, Elk Grove Village, Ill (Ms Finch and Dr Wasserman); and the
Department of Pediatrics, University of Vermont College of Medicine, Burlington
(Dr Wasserman).
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