Requiring Pyuria for UTI Diagnosis May Miss Infections
Research By: Stephanie Davis-Rodriguez, MD, MS
Post Date: February 6, 2025 | Publish Date: Nov. 20, 2024
Automated screening methods still miss up to 1 in 5 UTIs in febrile infants and toddlers. The reason—according to researchers of a study published in Pediatrics—is clinicians choosing not to order urine cultures due to the absence of pyuria.
Stephanie Davis-Rodriguez, MD, MS, an attending physician in the Division of Hospital Medicine at Cincinnati Children’s, and researchers from the Children’s Hospital of Pittsburgh and Children’s National Hospital wanted to see if automation improved the accuracy of urinalysis as a screening test for UTI.
They focused on tests assessing pyuria because the last published guidelines from the American Academy of Pediatrics (AAP) stated pyuria should be required for the diagnosis of UTI. The recommendation led many centers to only perform urine cultures for children with abnormal urinalysis test results.
“Most of us rely on national guidelines from the AAP or CDC or a similar entity to summarize the newest research and provide recommendations,” Davis-Rodriguez says. “The goal of the AAP’s guidelines was to prevent overtreating asymptomatic bacteriuria and contaminated samples. But any time you make a big change in practice you have to study it to make sure it’s working and to make sure there aren’t any unintended consequences.”
The researchers analyzed data from 4,188 children aged 1 to 35 months who underwent catheterization for a suspected UTI at Cincinnati Children’s, Children’s Hospital of Pittsburgh or Children’s National Hospital between June 2019 and April 2023. They compared five tests for pyuria, using a positive urine culture as the gold standard. They found that about 20% of children with a confirmed UTI (via culture) showed no pyuria, meaning pyuria tests can miss some cases.
According to the study’s findings, the rate of asymptomatic bacteriuria is about 2 in 1,000, with contamination occurring in about 5 in 1,000. “So even rounding up and assuming 1 in 100 are not real infections, the number of UTIs we’re missing is still much higher than what we estimate the rate of asymptomatic bacteriuria or contamination to be,” Davis-Rodriguez says.
She adds: “We are constantly balancing not wanting to miss a diagnosis with overtesting, which can lead to unnecessary antibiotic use, antibiotic resistance, unnecessary imaging or invasive testing. In this case, we think the harm of missing 1 in 5 UTIs outweighs the harm of overtesting 1 in 100. More work needs to be done to confirm our findings and look at the consequences of missing these UTIs.”
Diagnosing UTIs accurately and expeditiously is important because younger children are more prone to pyelonephritis, which can lead to kidney scarring and chronic kidney problems as an adult, Davis-Rodriguez notes.
The AAP UTI guideline is retired, but many clinicians still follow its recommendations. Davis-Rodriguez and her co-authors hope their findings—and those of similar studies—will be considered when the professional association plans its next guidelines.
“It’s a pretty simple take-home message, but it’s an important one,” she says.
The researchers are also participating in a larger study designed to identify urine biomarkers that are better at detecting UTIs than urinalysis, and at tests to differentiate a lower UTI from pyelonephritis.
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| Original title: | Accuracy of Screening Tests for the Diagnosis of Urinary Tract Infections in Young Children |
| Published in: | Pediatrics |
| Publish date: | Nov. 20, 2024 |
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The Research Horizons blog features news and insights about the latest discoveries and innovations developed by the scientists of Cincinnati Children's. This blog does not provide medical advice, diagnosis, or treatment.
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