Research ArticleSystematic Review

Clinical Features for the Diagnosis of Pediatric Urinary Tract Infections: Systematic Review and Meta-Analysis

Hanne A. Boon, Ann Van den Bruel, Thomas Struyf, Andreas Gillemot, Dominique Bullens and Jan Y. Verbakel
The Annals of Family Medicine September 2021, 19 (5) 437-446; DOI: https://doi.org/10.1370/afm.2684

Article Figures & Data

Figures

  • Figure 1a.
    Figure 1a.

    Likelihood ratios and posttest disease probabilities for urinary symptoms (dumbbell plots).

    CC = clean-catch urine samples; D = diaper urine samples; LR– = negative likelihood ratio; LR+ = positive likelihood ratio; UTI = urinary tract infection.

    a Data from Pylkkänen et al were not included in the meta-analysis.

  • Figure 1b.
    Figure 1b.

    Likelihood ratios and posttest disease probabilities for urine appearance (dumbbell plots).

    CC = clean-catch urine samples; D = diaper urine samples; LR– = negative likelihood ratio; LR+ = positive likelihood ratio; UTI = urinary tract infection.

    a Data from Pylkkänen et al were not included in the meta-analysis.

  • Figure 1c.
    Figure 1c.

    Likelihood ratios and posttest disease probabilities for clinical examination features (dumbbell plots).

    CC = clean-catch urine samples; D = diaper urine samples; LR– = negative likelihood ratio; LR+ = positive likelihood ratio; UTI = urinary tract infection.

    a Data from Pylkkänen et al were not included in the meta-analysis.

  • Figure 2.
    Figure 2.

    HSROC curve analysis of body temperature for urinary tract infection.

    AUC = area under the ROC curve; HSROC = hierarchical summary receiver operating characteristic; ROC = receiver operating characteristic.

    Note: HSROC curve analysis of body temperature for urinary tract infection in children, showing sensitivity vs 1-specificity at each threshold. The thresholds provided in primary studies are indicated on the graph. The CIs of the estimates are indicated as dashed lines. (Sample size = 43,570, including data from 16 primary studies).

  • Figure 3.
    Figure 3.

    Original ROC curve analysis of clinical prediction rules for urinary tract infections.

    CC = clean-catch urine samples; D = diaper urine samples; DUTY = Diagnosis of Urinary Tract Infection in Young Children; NICE = National Institute for Health and Care Excellence; p = points; ROC = receiver operating characteristic; UTI = urinary tract infection; UTIcalc = UTI Calculator; var = variable.

    Note: ROC curve analysis showing sensitivity vs 1-specificity at each threshold. The cutoff for a positive rule is shown next to each point on the graph. Each symbol represents the diagnostic test accuracy of 1 prediction rule for urinary tract infection in children.

    a Derivation studies.

    b Score ≥6 on Clinical Global Impression – Severity scale (0-10).

Tables

  • Table 1.

    Diagnostic Accuracy of Clinical Features for Urinary Tract Infection (Summary Estimates)

    Clinical FeatureNo. StudiesaNSummary Sensitivity, % (95% CI)Summary Specificity, % (95% CI)Summary LR+ (95% CI)Summary LR− (95% CI)
    Red Flags (LR+ ≥4) or Features (LR− <0.25)
    Hematuria  3  5,6154 (2-8)99 (97-100)4.23 (1.71-10.44)0.97 (0.94-1.00)
    Cloudy urine  4  3,86669 (30-92)85 (72-92)4.55 (3.73-5.56)0.36 (0.13-1.02)
    Malodorous urine  4  7,10931 (12-59)93 (75-98)4.13 (2.27-7.49)0.75 (0.58-0.98)
    No circumcision  8  6,71288 (52-98)52 (23-80)1.81 (1.15-2.87)0.24 (0.08-0.72)
    Amber Signs (LR+ 2-4 or LR− 0.25-0.5)
    Dysuria  7  5,41340 (19-66)88 (80-93)3.28 (2.22-4.86)0.68 (0.47-1.00)
    Frequency  4  5,66836 (22-53)84 (74-90)2.21 (1.78-2.75)0.76 (0.65-0.90)
    Bed wetting  3  5,43621 (12-32)92 (84-97)2.70 (1.46-4.99)0.86 (0.78-0.95)
    Previous UTI  7  7,54615 (9-24)94 (88-97)2.31 (1.73-3.10)0.91 (0.86-0.96)
    No source of infection  420,96484 (74-91)45 (18-75)1.53 (0.92-2.54)0.35 (0.22-0.55)
    Signs With LR+ <2 or LR− >0.5
    Diarrhea  724,64020 (12-30)78 (73-83)0.91 (0.68-1.22)1.03 (0.96-1.10)
    Vomiting  710,50527 (19-38)69 (61-76)0.89 (0.74-1.06)1.05 (1.00-1.12)
    Abdominal pain  6  5,39729 (14-51)84 (64-94)1.86 (0.82-4.22)0.84 (0.67-1.07)
    No cough  420,94681 (33-97)32 (7-76)1.19 (0.93-1.52)0.61 (0.34-1.07)
    Irritability  5  5,39515 (4-48)85 (63-95)1.00 (0.67-1.48)1.00 (0.93-1.07)
    Abnormal appearance  426,52536 (17-60)70 (50-85)1.21 (1.02-1.44)0.91 (0.80-1.04)
    Age <12 mo  3  2,11067 (47-83)41 (28-55)1.13 (1.02-1.26)0.81 (0.61-1.07)
    Female1547,35166 (57-74)47 (42-52)1.24 (1.11-1.39)0.73 (0.58-0.91)
    White1042,45650 (34-65)58 (42-73)1.18 (0.96-1.46)0.87 (0.73-1.04)
    Hispanic  734,07412 (4-32)89 (76-95)1.03 (0.74-1.44)1.00 (0.95-1.05)
    Asian  524,6235 (4-7)96 (95-97)1.42 (1.09-1.86)0.98 (0.97-1.00)
    Non-African American1042,39785 (76-91)27 (14-45)1.17 (1.02-1.33)0.55 (0.48-0.63)

    • LR− = negative likelihood ratio; LR+ = positive likelihood ratio; UTI = urinary tract infection.

    • ↵a Data from Pylkkänen et al38 were not included in the meta-analysis; bivariate random effects model by Chu and Cole.21

Additional Files

  • Visual Abstract

    PNG file

  • Supplemental materials

    Supplemental Appendixes 1-7; Supplemental Table, Supplemental Figure
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