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Make the Diagnosis: Urinary Tract Infection, Child

Prior Probability

The prevalence of urinary tract infection (UTI) in children varies with age and the clinical setting.1 See Table 59-1 for the prevalence rates of UTI in children with fever.

Table 59-1Prevalence of UTI in Febrile Infants and Children With No Obvious Source of Fever

Population in Whom UTI Should Be Considered

A UTI should be considered in infants with a temperature ≥ 38°C. Verbal children will typically have symptoms of dysuria, increased frequency of urination, urgency, incontinence, fever, abdominal pain, suprapubic discomfort, back pain, or vaginal/penile discharge.

Assessing the Likelihood of a UTI

Febrile Infants (age 0 to 24 months)

A temperature reported by the parents as > 40°C is the most useful finding from the history (likelihood ratio [LR] 3.2-3.3). Black infants are about half as likely to have a UTI as nonblack infants (LR for black infants, 0.52; 95% confidence interval [CI], 0.29-0.73).

When an infant has a temperature > 39°C that has lasted more than 48 hours, and there is no other obvious source for the fever (upper respiratory tract infection, acute otitis media, or acute gastroenteritis), the likelihood of a UTI rises fourfold (LR, 4.0; 95% CI, 1.2-13). The presence of another source for fever, however, does not rule a UTI (LR 0.69; 95% CI 0.55-0.80). The presence of suprapubic tenderness is also useful (LR, 4.4; 95% CI 1.6-12). For male infants with fever, the lack of circumcision makes a UTI more likely (summary LR, 2.8; 95% CI, 1.9-4.3); circumcised male infants are thus less likely to have a UTI as the cause of a febrile illness (LR, 0.33; 95% CI, 0.18-0.63).

Verbal Children

See Table 59-2. In verbal children with urinary symptoms, the presence of abdominal pain (LR, 6.3; 95% CI, 2.5-16), back pain (LR, 3.6; 95% CI, 2.1-6.1), or new-onset urinary incontinence (LR, 4.6; 95% CI, 2.8-7.6) are the most useful findings. Offensive urine odor, a symptom that prompts patient's concern for a UTI, does not change the likelihood of infection (the LR CI crosses 1.0 both for the presence and absence of odor). Overall, the absence of individual symptoms or signs does little to change the probability of a UTI since the LR- ...

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