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Research ArticleOriginal Research

Improving the Diagnosis and Treatment of Urinary Tract Infection in Young Children in Primary Care: Results from the DUTY Prospective Diagnostic Cohort Study

Alastair D. Hay, Jonathan A. C. Sterne, Kerenza Hood, Paul Little, Brendan Delaney, William Hollingworth, Mandy Wootton, Robin Howe, Alasdair MacGowan, Michael Lawton, John Busby, Timothy Pickles, Kate Birnie, Kathryn O’Brien, Cherry-Ann Waldron, Jan Dudley, Judith Van Der Voort, Harriet Downing, Emma Thomas-Jones, Kim Harman, Catherine Lisles, Kate Rumsby, Stevo Durbaba, Penny Whiting and Christopher C. Butler
The Annals of Family Medicine July 2016, 14 (4) 325-336; DOI: https://doi.org/10.1370/afm.1954
Alastair D. Hay
1Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Clifton, Bristol, United Kingdom
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  • For correspondence: alastair.hay@bristol.ac.uk
Jonathan A. C. Sterne
2School of Social and Community Medicine, University of Bristol, Clifton, Bristol, United Kingdom
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Kerenza Hood
3South East Wales Trials Unit (SEWTU), Centre for Trials Research, Cardiff University, Heath Park, Cardiff, United Kingdom
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Paul Little
4Primary Care and Population Science, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, United Kingdom
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Brendan Delaney
5Guys’ 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
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William Hollingworth
2School of Social and Community Medicine, University of Bristol, Clifton, Bristol, United Kingdom
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Mandy Wootton
6Specialist Antimicrobial Chemotherapy Unit, Public Health Wales Microbiology Cardiff, University Hospital Wales, Heath Park, Cardiff, United Kingdom
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Robin Howe
6Specialist Antimicrobial Chemotherapy Unit, Public Health Wales Microbiology Cardiff, University Hospital Wales, Heath Park, Cardiff, United Kingdom
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Alasdair MacGowan
7North Bristol NHS Trust, Southmead Hospital, Westbury-on-Trym, Bristol, United Kingdom
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Michael Lawton
2School of Social and Community Medicine, University of Bristol, Clifton, Bristol, United Kingdom
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John Busby
2School of Social and Community Medicine, University of Bristol, Clifton, Bristol, United Kingdom
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Timothy Pickles
3South East Wales Trials Unit (SEWTU), Centre for Trials Research, Cardiff University, Heath Park, Cardiff, United Kingdom
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Kate Birnie
2School of Social and Community Medicine, University of Bristol, Clifton, Bristol, United Kingdom
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Kathryn O’Brien
8Division of Population Medicine, School of Medicine, Cardiff University, Heath Park, Cardiff, United Kingdom
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Cherry-Ann Waldron
3South East Wales Trials Unit (SEWTU), Centre for Trials Research, Cardiff University, Heath Park, Cardiff, United Kingdom
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Jan Dudley
9Bristol Royal Hospital for Children, University Hospitals Bristol, NHS Foundation Trust, Bristol, United Kingdom
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Judith Van Der Voort
10Department of Paediatrics and Child Health, University Hospital of Wales, Heath Park, Cardiff, United Kingdom
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Harriet Downing
1Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Clifton, Bristol, United Kingdom
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Emma Thomas-Jones
3South East Wales Trials Unit (SEWTU), Centre for Trials Research, Cardiff University, Heath Park, Cardiff, United Kingdom
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Kim Harman
4Primary Care and Population Science, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, United Kingdom
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Catherine Lisles
3South East Wales Trials Unit (SEWTU), Centre for Trials Research, Cardiff University, Heath Park, Cardiff, United Kingdom
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Kate Rumsby
4Primary Care and Population Science, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, United Kingdom
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Stevo Durbaba
11King’s College London, Division of Health and Social Care Research, Department of Primary Care and Public Health Sciences, London, United Kingdom
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Penny Whiting
12NIHR CLAHRC West, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
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Christopher C. Butler
13Nuffield 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
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Abstract

PURPOSE 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.

METHODS 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.

RESULTS 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.

CONCLUSIONS 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.

  • urinary tract infections
  • primary health care
  • pediatrics
  • diagnosis
  • anti-bacterial agents
  • Received for publication November 20, 2015.
  • Revision received March 24, 2016.
  • Accepted for publication April 7, 2016.
  • © 2016 Annals of Family Medicine, Inc.
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Improving the Diagnosis and Treatment of Urinary Tract Infection in Young Children in Primary Care: Results from the DUTY Prospective Diagnostic Cohort Study
Alastair D. Hay, Jonathan A. C. Sterne, Kerenza Hood, Paul Little, Brendan Delaney, William Hollingworth, Mandy Wootton, Robin Howe, Alasdair MacGowan, Michael Lawton, John Busby, Timothy Pickles, Kate Birnie, Kathryn O’Brien, Cherry-Ann Waldron, Jan Dudley, Judith Van Der Voort, Harriet Downing, Emma Thomas-Jones, Kim Harman, Catherine Lisles, Kate Rumsby, Stevo Durbaba, Penny Whiting, Christopher C. Butler
The Annals of Family Medicine Jul 2016, 14 (4) 325-336; DOI: 10.1370/afm.1954

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Improving the Diagnosis and Treatment of Urinary Tract Infection in Young Children in Primary Care: Results from the DUTY Prospective Diagnostic Cohort Study
Alastair D. Hay, Jonathan A. C. Sterne, Kerenza Hood, Paul Little, Brendan Delaney, William Hollingworth, Mandy Wootton, Robin Howe, Alasdair MacGowan, Michael Lawton, John Busby, Timothy Pickles, Kate Birnie, Kathryn O’Brien, Cherry-Ann Waldron, Jan Dudley, Judith Van Der Voort, Harriet Downing, Emma Thomas-Jones, Kim Harman, Catherine Lisles, Kate Rumsby, Stevo Durbaba, Penny Whiting, Christopher C. Butler
The Annals of Family Medicine Jul 2016, 14 (4) 325-336; DOI: 10.1370/afm.1954
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Keywords

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  • anti-bacterial agents

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