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Three Part Question

In [children with pyrexia with suspected UTI] is [dipstick urinalysis as sensitive as microscopy] in [ruling out infection]?

Clinical Scenario

A very anxious mother brings her 4 year old daughter to the emergency department concerned about her persistent fever. Examination reveals that she does indeed have a temperature of 37.6ºC. She has no obvious signs of localised infection, so you decide that you need to test her urine to see whether she has got a UTI. After much coaxing she provides you with a sample but you now wonder if dipstick analysis is sufficient for diagnosis, or whether you ought to arrange for urgent microscopy.

Search Strategy

Medline 1966-08/01 using the OVID interface.
{(exp adolescence/ or exp child/ or exp child of impaired parents/ or exp child, abandoned/ or exp child, exceptional/ or exp child, hospitalized/ or exp child, institutionalized/ or exp child, preschool/ or exp child, unwanted/ or exp disabled children/ or exp homeless youth/ or exp infant/ or exp only child/ OR child$.mp) OR (exp pediatrics/ OR pediatric$.mp OR paediatric$.mp)} AND (exp Indicators/ and reagents/ OR exp Reagent strips/ OR exp Urinalysis/ OR dipstick.mp) AND (exp Urinary tract infections/ OR urinary tract infection.mp) AND (exp "sensitivity and specificity"/ or "sensitivity and specificity".mp OR diagnos$.mp OR exp Diagnosis/) LIMIT to human AND english.

Search Outcome

156 papers found. Of these, one was a recent meta-analysis which included all those papers identified as answering the 3 part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Gorelick MH and Shaw KN, 1999, USA	Children from 26 previous studies age range from 0-21 years and from outpatients', wards and emergency departments	Meta-analysis	Sensitivity amd specificity of Gram Stain, Leukocyte esterase, nitrite and pyuria against a gold standard of urine culture. Only tests using definition of UTI as >100,000 colony forming units used for calculating sensitivity and specificity	Sensitivity: Gram Stain 0.93, Leukocyte esterase or nitrite 0.88, Pyuria 0.67 (>5 WC), 0.77 (>10 WC) Specificitiy: Gram Stain 0.95, Leukocyte esterase and nitrite 0.96	Significant heterogeneity between tests performed, method of collection, age group, setting and definition of UTI

Clinical Bottom Line

Children who present with fever and who have positive dipstick testing for leukocyte esterase and nitrite should be started on antibiotics and referred for further investigation. Dipstick testing would appear to have the sensitivity for children with negative testing to be discharged, with the urine being sent for gram stain and culture the following day rather than arranging urgent microscopy.

References

1. Gorelick MH, Shaw KN. Screening tests for urinary tract infection in children: A meta-analysis. Pediatrics 1999;104(5):e54.