Children prescribed antibiotics for UTIs not always tested

Ellen Wald, MD

Copp and colleagues investigated urine-testing trends (both the performance of urinalysis as well as urine culture) in pediatric patients aged younger than 18 years coded as having a UTI and treated with antibiotic. They derived their data from a large, private claims database that collects United Healthcare insurance enrollment information. They discovered that 32% of children aged younger than 2 years had neither a urinalysis nor culture performed before prescribing an antibiotic for a presumed UTI. In fact, children aged younger than 2 years were the least likely to have a urine culture performed. While pediatricians performed testing more often than other specialties, they did so in only 72% of cases. Furthermore, factors that place patients at increased risk for an antibiotic-resistant UTI (history of previous UTI, recent hospitalization, recent antibiotic exposure and presence of genitourinary anomaly) were not strongly associated with the use of urine cultures.

Although there is plenty of evidence that practitioners do not always follow published guidelines, these findings are very surprising for several reasons. It has been recognized for almost two decades, that UTI in children aged younger than 2 years (usually signaled by fever rather than dysuria), usually represents an episode of pyelonephritis rather than cystitis. Furthermore, during the time period studied, the recommendations for the management of UTI, especially pyelonephritis, in this young age group, involved the use of imaging procedures which might include a renal and bladder ultrasound as well as a voiding cystourethrogram. The latter study is expensive, invasive and uncomfortable, thereby emphasizing the need to be sure that a given patient, presumed to have a UTI, actually has a bona fide infection. The diagnosis of UTI can only be proven with certainty by the performance of a urine culture.

The second area of unexpected findings relate to a failure to perform urine cultures under conditions known to increase the risk of antibiotic-resistant infections. Furthermore, that urologists, the most likely specialist to see children with complicated urologic conditions, were the least likely to obtain urine cultures in children treated for UTI is startling.

UTI in children aged younger than 2 years is the most common serious bacterial infection that occurs in children. However, it is not so common, that the expense of its documentation, would be a burden on the health care system. Furthermore, initiating treatment of UTI without documentation threatens to foster the indiscriminate use of antibiotics thereby promoting additional unnecessary expense and fostering the emergence of antibiotic resistance, if treatment is undertaken in situations in which infection is not actually present. In addition, failure to document an infection or multiple infections places the patient and the practitioner in the uncomfortable situation of not knowing or being unable to verify whether patients qualify or are appropriate for more thorough evaluations or referral. Delay in specific evaluations and potential treatment of anatomic or functional problems may result.

While it is commonplace to treat suspected UTIs, especially those without fever, in adults without culture of urine, this is a practice that should not be adapted to children until there is convincing evidence that it is safe and effective. Ever for adults, many sources would recommend a minimum of a urinalysis in patients suspected to have UTI who do not have fever. In sexually active patients, it is important to remember that dysuria may reflect the presence of a sexually transmitted infection and that a screening urinalysis (identifying the presence of significant pyuria) will identify patients who are appropriately managed with either a urine culture for bacteria or evaluations for infections caused by Chlamydia trachomatics and Neisseria gonorrhea.

In summary, the failure to perform urinalysis and urine culture in children treated for UTI is counter to formal recommendation from AAP in the youngest children (aged 2 years and younger) and is of unproven safety and effectiveness in older children. This practice should be strongly discouraged in the absence of data to support it.