PT  - JOURNAL ARTICLE
AU  - Hay, Alastair D.
AU  - Sterne, Jonathan A. C.
AU  - Hood, Kerenza
AU  - Little, Paul
AU  - Delaney, Brendan
AU  - Hollingworth, William
AU  - Wootton, Mandy
AU  - Howe, Robin
AU  - MacGowan, Alasdair
AU  - Lawton, Michael
AU  - Busby, John
AU  - Pickles, Timothy
AU  - Birnie, Kate
AU  - O’Brien, Kathryn
AU  - Waldron, Cherry-Ann
AU  - Dudley, Jan
AU  - Van Der Voort, Judith
AU  - Downing, Harriet
AU  - Thomas-Jones, Emma
AU  - Harman, Kim
AU  - Lisles, Catherine
AU  - Rumsby, Kate
AU  - Durbaba, Stevo
AU  - Whiting, Penny
AU  - Butler, Christopher C.
TI  - Improving the Diagnosis and Treatment of Urinary Tract Infection in Young Children in Primary Care: Results from the DUTY Prospective Diagnostic Cohort Study
AID  - 10.1370/afm.1954
DP  - 2016 Jul 01
TA  - The Annals of Family Medicine
PG  - 325--336
VI  - 14
IP  - 4
4099  - http://www.annfammed.org/content/14/4/325.short
4100  - http://www.annfammed.org/content/14/4/325.full
SO  - Ann Fam Med2016 Jul 01; 14
AB  - 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.