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Three Part Question

In [children <5 years old presenting to the Emergency Department with a febrile convulsion] is [a urinary tract infection] a [common aetiology]?

Clinical Scenario

A 2-½ year-old girl has been brought to the Emergency Department with a simple febrile convulsion with unclear focus of infection on examination. She does not appear septic. Her parents say she is potty training and have noticed her urine has smelt strong the past day or two. You test a sample of her urine and diagnose an UTI. You wonder if an UTI is a common cause of febrile convulsions.

Search Strategy

OVID Medline <1966 – June Week 3 2005>
EMBASE <1980 – 2005 Week 26>
CINAHL <1982 – June Week 3 2005>
The Cochrane Library 2005 Issue 2.
Medline
(exp Urinary Tract Infections/ OR urinary tract infection$.mp. OR water infection$.mp. OR renal tract infection$.mp.) AND (exp Seizures, Febrile/ OR [seizure$.mp. AND {febrile.mp. OR pyrexia$.mp. OR exp FEVER/ OR fever$.mp.}] OR [convulsion$.mp. AND {febrile.mp. OR pyrexia$.mp. OR exp FEVER/ OR fever$.mp.}] OR [fit$.mp. AND {febrile.mp. OR pyrexia$.mp. OR exp FEVER/ OR fever$.mp.}] ) Limit to (humans and English language and ("infant (1 to 23 months)" or "preschool child (2 to 5 years)"))
EMBASE
(exp Urinary Tract Infections/ OR urinary tract infection$.mp. OR water infection$.mp. OR renal tract infection$.mp.) AND (exp Febrile Convulsion/ OR [seizure$.mp. AND {febrile.mp. OR pyrexia$.mp. OR exp FEVER/ OR fever$.mp.}] OR [convulsion$.mp. AND {febrile.mp. OR pyrexia$.mp. OR exp FEVER/ OR fever$.mp.}] OR [fit$.mp. AND {febrile.mp. OR pyrexia$.mp. OR exp FEVER/ OR fever$.mp.}] OR [exp CONVULSION/ AND {febrile.mp. OR pyrexia$.mp. OR exp FEVER/ OR fever$.mp.}] OR [exp "SEIZURE, EPILEPSY AND CONVULSION"/ AND {febrile.mp. OR pyrexia$.mp. OR exp FEVER/ OR fever$.mp.}]) Limit to (human and English language and (infant or preschool child <1 to 6 years>))
CINAHL
(exp Urinary Tract Infections/ OR urinary tract infection$.mp. OR water infection$.mp. OR renal tract infection$.mp.) AND (exp Convulsions, Febrile/ OR [exp Seizures/ AND {febrile.mp. OR pyrexia$.mp. OR exp FEVER/ OR fever$.mp.}] OR [seizure$.mp. AND {febrile.mp. OR pyrexia$.mp. OR exp FEVER/ OR fever$.mp.}] OR [exp Convulsions/ AND {febrile.mp. OR pyrexia$.mp. OR exp FEVER/ OR fever$.mp.}] OR OR [convulsion$.mp. AND {febrile.mp. OR pyrexia$.mp. OR exp FEVER/ OR fever$.mp.}] OR [fit$.mp. AND {febrile.mp. OR pyrexia$.mp. OR exp FEVER/ OR fever$.mp.}]) Limit to (English and (infant <1 to 23 months> or preschool child <2 to 5 years>))

Search Outcome

Medline: 13 papers found, 4 relevant.
Embase: 13 papers found, no new or relevant papers found.
CINAHL: 2 papers found, none relevant.
Cochrane Library: no relevant papers found.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
McIntyre PB, Gray SV and Vance JC. 1990. Australia.	307 children aged between 6 months and 5 years who presented with convulsions and fever during the calendar year 1984.	Prospective cohort study.	Number of patients with urine cultures performed.	272/307 (88.6%)	Not all children had their urine cultured. No details about how children were selected to have their urine cultured.
			Number of positive cultures.	7/272 (2.6%)
			Number without focal infection before cultures done.	6/7 (85.7%)
			Number with positive culture and female.	7/7 (100%)
			Number with positive culture and less than 2 years old.	6/7 (85.7%)
Lee P and Verrier-Jones K. 1991. UK.	403 children admitted to hospital with febrile convulsions.	Retrospective cohort study.	Number of patients with urine cultures performed.	228/403 (56.6%)	Data derived from abstract only. Not all children had urine cultured.
			Number of uncontaminated samples.	155/228 (68.0%)
			Number of probable infections.	13/155 (8.4%)
			Number of possible infections.	6/155 (3.9%)
Teach SJ and Geil PA. 1999. UAS.	243 encounters of 218 patients presenting to an emergency department of a Children's hospital with febrile convulsion during the calendar year 1996.	Retrospective cohort study.	Number of patients with urine cultures performed.	130/243 (53.5%)	Not every patient had his or her urine cultured. No information about how children were selected to have their urine cultured They only tested catheterised or clean voided urine.
			Number of positive cultures.	1/130 (0.7%, 95% CI 0.0%-2.2%)
Trainor JL, Hampers LC, Krug SE ad Listernick R. 2001. USA.	455 children aged 6 to 60 months, presenting to 7 emergency departments with their first simple febrile convulsion between July 1995 and December 1997.	Retrospective cohort study.	Number of patients with urine culture performed.	171/455 (37.6%)	Not all children had their urine cultured. No information about how the children were selected to have their urine cultured. Only urine from catheterisation or clean void was cultured.
			Number of positive results.	10/171 (5.9%, 95% CI 2.4%-9.4%).
			Number with positive culture and female.	60%
			Number less than 2 years old with positive culture.	8/127 (6.3%, 95% CI 2.1%-10.5%)

Comment(s)

Three of the four relevant papers were obtained in full, and data was derived from the abstract of the remaining paper. The number of positive cultures detected varied, ranging from 0.7% to 5.9%. Lee and Verrier-Jones defined their results as number of 'probable' urinary tract infections and number of 'possible' urinary tract infections, but as only the abstract was available, it is unknown what these terms mean. Only two studies (McIntyre et al and Trainor et al) gave further information about the children with positive urine cultures found in their studies.

Clinical Bottom Line

These studies suggest that a urinary tract infection is not an uncommon cause of febrile convulsions, especially in children less than 2 years old and female children.

References

1. McIntyre PB, Gray SV and Vance JC. Unsuspected bacterial infections in febrile convulsions. Medical Journal of Australia. 1990; 152(4):183-6
2. Lee P and Verrier-Jones K. Urinary Tract Infection in Febrile Convulsions. Archives of Disease in Childhood. 1991; 66(11):1287-90
3. Teach SJ and Geil PA. Incidence of bacteremia, urinary tract infections, and unsuspected bacterial meningitis in children with febrile seizures. Pediatric Emergency Care. 1999; 15 (1):9-12.
4. Trainor JL, Hampers LC, Krug SE ad Listernick R. Children with first-time simple febrile seizures are at low risk of serious bacterial illness. Academic Emergency Medicine. 2001; 8(8):781-7.