You’ve spent your morning locked in administrative meetings. After being serenaded at length by the budgetary mantra to cut costs while maintaining high-quality patient care, the chaos of your subsequent afternoon ED shift is almost a welcome contrast. The next chart in the rack, though, brings back memories of the morning’s subject matter…
Concerned parents have brought their 4-year old son to the ED with just over 24-hours of fever. History does not reveal a specific infectious focus. There is no vomiting, diarrhea, abdominal discomfort, or back pain. Hydration has been maintained. When asked about dysuria the patient giggles and hugs his mother instead of answering. His parents do not give any history of their child having complained of pain with urination. He is previously healthy, and uncircumcised. The nurse asks if you would like a urine sample sent to the lab. The dollar figures associated with unnecessary testing involuntary come to mind.
- History of UTI
- Temperature > 39 C
- Ill appearance
- Suprapubic tenderness
- Fever >24h
- Nonblack race
In uncircumcised male infants, the baseline risk of UTI is around 6%. The presence of any of the aforementioned UTI risk factors is sufficient to raise this probability to between 10% and 25%, mandating further urinalysis and culture. In the absence of all the above factors, the risk falls to under 2%, and can be managed conservatively with reassessment in 24-hours.
In circumcised males the baseline risk is lower (around 1%) so two or more risk factors (or suprapubic tenderness alone) need to be present before further testing would be required. For female infants, the presence of any UTI risk factor is sufficient to raise the probability of UTI above the 2% threshold supporting urinalysis.
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Reprinted from Annals of Emergency Medicine, “Does This Child Have a Urinary Tract Infection?”, May 2009, Rupinder Singh Sahsi and Christopher R. Carpenter, copyright 2009, with permission from Elsevier
The algorithm is different for verbal children who present with urinary or abdominal symptoms. In circumcised males with a low baseline probability of UTI (<1%) urinalysis and culture is only recommended in the presence of multiple signs and symptoms of UTI. For females and uncircumcised males, the presence of dysuria/frequency OR the presence of abdominal pain, back pain, or new-onset incontinence is needed before diagnostic testing is mandated. In all other cases, UTI is considered highly unlikely. In this situation, alternative diagnoses should be contemplated while ensuring appropriate follow up. The Caveat
Rupinder Sahsi, BSc MD is a faculty member and Technology Director of BEEM (Best Evidence in Emergency Medicine) and is an assistant clinical professor of emergency medicine at McMaster University. He practices in the emergency departments of Kitchener-Waterloo, Ontario, Canada.