Many pediatricians do not comply with AAP UTI guidelines

Recent data show a significant number of pediatricians do not comply with the AAP guidelines for the management of urinary tract infections in infants.

Karl Coutinho, MD, of Mount Sinai Medical Center, and colleagues evaluated physician compliance with the AAP urinary tract infection (UTI) guidelines released in 2011. Between September 2012 and January 2013, 155 pediatricians completed surveys that questioned their preferred methods of sampling urine in patients aged 2 to 24 months, with and without risk factors for UTIs. Study participants were registered members of the New Jersey chapter of the AAP.

Eighty percent of respondents considered themselves familiar with AAP 2011 guidelines for UTIs in infants. Forty-two percent of respondents reported they “only sometimes” changed their practice to adhere to the guidelines, and 3% reported they did not modify their practice according to the guidelines. Conversely, 29% of physicians revised their practices to completely adhere to the AAP’s recommendations, and 17% reported their practice was already in compliance with the guidelines.

Urethral catheterization was the preferred method of urine collection among 46% of physicians, and 35% reported that their initial method of urine collection depended on the specific clinical scenario and temperament of the child. Other methods, such as suprapubic aspiration or a bagged specimen for culture, were used by 3% and 8% of respondents, respectively.

Regarding febrile, circumcised boys with no risk factors for UTI, urethral catheterization was the most preferred method of urine collection, accounting for 35% of respondents’ preferences. Twenty-one percent of physicians reported they would use bagged urine collection alone for culture; the same amount reported they would not collect urine at all. Three percent of physicians reported suprapubic aspiration and other techniques, such as sending to an urologist or ED, as their preferred method of urine collection.

Forty-nine percent of physicians preferred urethral catheterization to treat girls with no risk factors for UTI, while 14% preferred bagged specimens. Seventeen percent of physicians said they would not collect urine specimens at all. Again, suprapubic aspiration and other techniques made up 3% of physicians’ preferences.

For febrile, uncircumcised boys, preference for urethral catheterization increased as with the number of risk factors, ranging from 61% for one risk factor to 78% for four risk factors. Bagged specimens were preferred with decreasing frequency in terms of the number of risk factors present and ranged from 7% for one risk factor to 3% for four risk factors. Overall, preference for bagged specimens for culture in febrile, uncircumcised boys ranged from 18% to 6% as the risk factors for UTI ranged between one and four.

Catheterized specimens were preferred by 62% to 81% of physicians when treating febrile girls with one to four risk factors for UTI. Preference for bagged specimens decreased as febrile girls’ risk factors for UTI increased, ranging from 13% for one risk factor to 3% for four risk factors.

“[Suprapubic aspiration] is the cleanest method for obtaining urine and is considered by the AAP as the gold standard for detecting UTI. However, we found it to be the least popular, with only four of 155 respondents preferring it as an initial test.

Our survey results indicate that a considerable percentage of practitioners deviate from the AAP recommendations. The resulting misdiagnoses, overtreatment, and unnecessary workups may lead to adverse events and increased health care costs. More research is required to better assess the underlying causes of this noncompliance in order to better educate practitioners on preferred clinical practice,” the researchers concluded.

Disclosure: The researchers report no relevant financial disclosures.

For more information:

Coutinho K. Clin Pediatr. 2014; doi:10.177/0009922814536263.

AAP. Pediatrics. 2011; doi:10.1542/peds.2011-1330.