Should you test for urinary tract infection in children with respiratory symptoms?

QUESTION: An 8-month-old boy presented to our clinic with a 3-day history of fever. He has had a cough and rhinorrhea since the onset of the fever, and his 4-year-old sibling has recently had cough and cold symptoms. I have heard that the presence of respiratory symptoms means that urinary tract infection (UTI) is less likely. In infants with fever and respiratory symptoms, who should have a sample collected for urinalysis for UTI? ANSWER: The approach to diagnosing febrile infants who have respiratory symptoms varies by age. Urinalysis should be done for all febrile infants younger than 2 months of age, regardless of whether they have respiratory symptoms. Clinicians should assess risk factors for UTI in every infant between 2 and 24 months of age and should not exclude the diagnosis of UTI based on respiratory symptoms alone. Use of a predictive tool to estimate the pretest probability of UTI would aid decision making about patients in this population.

Diagnostic and antibiotic stewardship lessons: an outpatient assessment of symptomatic reflex urinalysis ordering accuracy using an electronic best-practice alert.

BACKGROUND: It is not well known how reliably clinicians order reflex urinalysis to microscopy and culture (rUA-cx) for outpatient urinary tract infection (UTI) workup. Antibiotic appropriateness cannot be fully appreciated until the prevalence of UTIs and asymptomatic bacteriuria (ASB) are realized. OBJECTIVE: This quality improvement study has two major aims, first to determine UTI symptom accuracy for rUA-cx ordering and second, to confirm UTI and ASB cases by integrating rUA-cx and cascaded urinalysis results. Antibiotic utilization and diagnostic coding were secondarily linked to UTIs and ASB. METHODS: An electronic best-practice alert informed the ordering of two rUA-cx options: symptomatic- rUA-cx specifically for dysuria, frequency, urgency, costovertebral pain, suprapubic pain or fever versus non-specific-rUA-cx for vague complaints. UTI symptoms were verified by chart review. Confirmed UTI was defined as a significant culture with UTI symptoms and ASB as a significant culture without UTI symptoms. RESULTS: rUA-cx (2065) were prospectively collected over 6 months from female patients at risk for uncomplicated UTIs. Symptomatic-rUA-cx and non-specific-rUA-cx were associated with UTI symptoms for 53% (809/1527) and 20% (107/538), respectively. Overall, 44% (916/2065) of all rUA-cx had UTI symptoms. rUA-cx were overordered by a factor of 9 (2065/225) for every confirmed UTI. The UTI-to-ASB relative ratio was 2.6 (225/86). Regarding UTI-relevant antibiotics, 39% (214/553) were appropriately associated with UTI whereas only 22% (74/339) of inappropriate antibiotics were captured by the ASB definition, underestimating the problem 4-fold. CONCLUSIONS: UTI and ASB remain challenging to categorize despite a meticulous method that applied acceptable criteria.

Summary Paper on the 2023 European Association of Urology Guidelines on the Management of Non-neurogenic Male Lower Urinary Tract Symptoms.

CONTEXT: Lower urinary tract symptoms (LUTS) are common, often bothersome, and have multifactorial aetiology. OBJECTIVE: To present a summary of the 2023 version of the European Association of Urology guidelines on the management of male LUTS. EVIDENCE ACQUISITION: A structured literature search from 1966 to 2021 selected the articles with the highest certainty evidence. The Delphi technique consensus approach was used to develop the recommendations. EVIDENCE SYNTHESIS: The assessment of men with LUTS should be practical. A careful medical history and physical examination are essential. Validated symptom scores, urine test, uroflowmetry, and postvoid urine residual, as well as frequency-volume charts for patients with nocturia or predominately storage symptoms should be used. Prostate-specific antigen should be ordered if a diagnosis of prostate cancer changes the treatment plan. Urodynamics should be performed for selected patients. Men with mild symptoms are candidates for watchful waiting. Behavioural modification should be offered to men with LUTS prior to, or concurrent with, treatment. The choice of medical treatment depends on the assessment findings, predominant type of symptoms, ability of the treatment to change the findings, and the expectations to be met in terms of the speed of onset, efficacy, side effects, and disease progression. Surgery is reserved for men with absolute indications, and for patients who fail or prefer not to receive medical therapy. Surgical management has been divided into five sections: resection, enucleation, vaporisation, and alternative ablative and nonablative techniques. The choice of surgical technique depends on patient's characteristics, expectations, and preferences; surgeon's expertise; and availability of modalities. CONCLUSIONS: The guidelines provide an evidence-based approach for the management of male LUTS. PATIENT SUMMARY: A clinical assessment should identify the cause(s) of symptoms and define the clinical profile and patient's expectations. The treatment should aim to ameliorate symptoms and reduce the risk of complications.

Predictive model for urosepsis in patients with Upper Urinary Tract Calculi based on ultrasonography and urinalysis using artificial intelligence learning.

PURPOSE: To construct a predicting model for urosepsis risk for patients with upper urinary tract calculi based on ultrasound and urinalysis. MATERIALS AND METHODS: A retrospective study was conducted in patients with upper urinary tract calculi admitted between January 2016 and January 2020. The patients were randomly grouped into the training and validation sets. The training set was used to identify the urosepsis risk factors and construct a risk prediction model based on ultrasound and urinalysis. The validation set was used to test the performance of the artificial neural network (ANN). RESULTS: Ultimately, 1716 patients (10.8% cases and 89.2% control) were included. Eight variables were selected for the model: sex, age, body temperature, diabetes history, urine leukocytes, urine nitrite, urine glucose, and degree of hydronephrosis. The area under the receiver operating curve in the validation and training sets was 0.945 (95% CI: 0.903-0.988) and 0.992 (95% CI: 0.988-0.997), respectively. Sensitivity, specificity, and Yuden index of the validation set (training set) were 80.4% (85.9%), 98.2% (99.0%), and 0.786 (0.849), respectively. CONCLUSIONS: A preliminary screening model for urosepsis based on ultrasound and urinalysis was constructed using ANN. The model could provide risk assessments for urosepsis in patients with upper urinary tract calculi.

Enuresis in Children: Common Questions and Answers.

Nocturnal enuresis is defined as nighttime urinary incontinence occurring at least twice weekly in children five years and older. Approximately 14% of children have spontaneous resolution each year without treatment. Subtypes of nocturnal enuresis include nonmonosymptomatic enuresis and primary and secondary monosymptomatic nocturnal enuresis. Monosymptomatic enuresis is characterized by nighttime bedwetting without daytime urinary incontinence. Pathophysiology of primary monosymptomatic nocturnal enuresis may be due to sleep arousal disorder, overproduction of urine, small bladder storage capacity, or detrusor overactivity. Children with nonmonosymptomatic enuresis have daytime and nighttime symptoms resulting from a variety of underlying etiologies. An in-depth history is an integral component of the initial evaluation. For all types of enuresis, a comprehensive physical examination and urinalysis should be performed to help identify the cause. It is important to reiterate to the family that bedwetting is not the child's fault. Treatment should begin with behavioral modification, which then progresses to enuresis alarm therapy and oral desmopressin. Enuresis alarm therapy is more likely to produce long-term success; desmopressin yields earlier symptom improvement. Treatment of secondary monosymptomatic nocturnal enuresis and nonmonosymptomatic enuresis should primarily focus on the underlying etiology. Pediatric urology referral should be made for refractory cases in which underlying genitourinary anomalies or neurologic disorders are more likely. .

Association between urine microscopy and severe acute kidney injury in critically ill patients following non-cardiac surgery: a prospective cohort study.

BACKGROUND: Acute kidney injury (AKI) is a common and adverse complication following non-cardiac surgery. Evidence have shown urine microscopy could help early detection, differentiating the causes and predicting the progression of AKI. However, little evidence is available on AKI after non-cardiac surgery. Thus, we investigated the association between urine microscopy and severe AKI in critically ill patients after non-cardiac surgery. METHODS: This was a single-center prospective cohort study. The primary outcome was severe AKI, defined as stage 2 or 3 according to maximal KDIGO criteria within 7 days following non-cardiac surgery. Urine microscopy immediately, 6 and 12 hours after surgical intensive care unit (SICU) admission were examined and graded by a urine microscopy score (UMS) based on the observed quantification of renal tubular cells and casts in the sediment. Then, multivariate Logistic regression models were used to analyze the associations between UMS and postoperative severe AKI. RESULTS: From May 20, 2019 to November 24, 2020, 661 patients were enrolled with 147 patients (22.2%) developing postoperative severe AKI. Multivariate Logistic regression model showed elevated UMS (≥1) 6 and 12 hours after SICU admission were independently associated with postoperative severe AKI (OR 2.200, 95% CI: 1.182-4.095, P=0.013 and OR 2.949, 95% CI: 1.657-5.248, P<0.001, respectively). Furthermore, higher UMS 6 hours after SICU admission demonstrated correlation with greater risk of severe AKI with OR 3.887 (95% CI: 1.430-10.563) for UMS ≥3 and OR 2.429 (95% CI: 1.237-4.770) for UMS =1-2. The specificity and sensitivity of UMS ≥1 for severe AKI was 93.8% (95% CI: 91.7-95.9%) and 15.6% (95% CI: 9.7-21.5%), respectively. While the negative and positive predictive value was 79.5% (95% CI: 76.3-82.7%) and 41.8% (95% CI: 28.8-54.8%), respectively. In addition, patients with higher UMS (≥3, 1-2 and 0) had significantly more postoperative complications and longer SICU stay; and they also showed a trend toward other adverse postoperative outcomes. CONCLUSIONS: Early urine microscopy was independently associated with severe AKI in critically ill patients following non-cardiac surgery with higher UMS related to greater risk. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03880110.

Urine sediment findings were milder in patients with COVID-19-associated renal injuries than in those with non-COVID-19-associated renal injuries.

BACKGROUND: Acute renal injury is an important complication of coronavirus disease 2019 (COVID-19). Both COVID-19-specific mechanisms, such as damage to the renal parenchyma by direct infection, and non-specific mechanisms, such as the pre-renal injury factors, have been proposed to be involved in COVID-19-associated renal injuries. In this study, we aimed to elucidate the characteristics of COVID-19-associated renal injuries, focusing mainly on urine sediment findings. METHODS: We compared the urine sediment findings and their associations with renal functions or urinary clinical parameters between subjects with COVID-19 and subjects without COVID-19 with acute renal injuries. RESULTS: We found that the number of urine sediment particles and the levels of N-acetyl-ß-D-glucosaminidase, α1-microglobulin, liver type fatty acid-binding protein, and neutrophil gelatinase-associated lipocalin were associated with the severity of COVID-19. In addition, we observed that the number of granular casts, epithelial casts, waxy casts, and urinary chemical marker levels were lower in the subjects with COVID-19 than subjects without COVID-19 with acute renal injuries when the subjects were classified according to their renal function. CONCLUSIONS: These results suggest that pre-renal injury factors might be largely involved in the pathogenesis of COVID-19-associated renal injuries compared with non-COVID-19-associated renal injuries arising from surgery or sepsis.

Managing recurrent urinary tract infections in kidney transplant recipients using smartphone assisted urinalysis test.

BACKGROUND: Urinary tract infection is the most frequent infectious complication in allograft recipients with poor outcomes. The study aimed to assess the effect of self-testing urine dipsticks at home, with the assistance of smartphone technology, on the occurrence of urinary tract infection (UTI)-associated complications and frequency and length of hospital admissions. METHOD: We performed a retrospective cohort study of kidney transplant recipients with a history of recurrent UTI who used a newly introduced smartphone-assisted dipsticks urinalysis test for self-monitoring. Participants self-administered the home urinalysis test with symptom onset. Antibiotics were prescribed if an infection was suspected, and home urinalysis was positive. The incidence of urinary infections, hospitalisations, and complications was evaluated before and during the home urinalysis period. Remote and face-to-face interactions with healthcare personnel were also assessed (cases acted as their controls). RESULTS: Nineteen participants were included in the study. A total of 89.5% were females. Ninety home urinalysis tests were conducted over a mean period of 7 months. Sixty-one of these were pre-antibiotic. A total of 42.2% of all tests and 47.5% of the pre-antibiotic tests were positive. UTI-related hospitalisations were lower by 75% during the home urinalysis period; mean 1.26 (0.8-1.6) versus 0.32 (-0.01-0.6). The incidence of infection-related complications was also 65% lower; mean 1.52 (0.8-2.2) versus 0.52 (-0.2-1.2) during the same period. The number of face-to-face interactions was slightly lower; mean 1.9 (1.1-2.2) versus 1.7 (0.6-2.8), with more remote interactions; mean 6.0 (3.7-8.5) versus 10.4 (6.5-14.3), during smartphone urinalysis. Fifty per cent of antibiotic-treated UTI episodes had antibiotics within 24 h, rising to 82% within 48 h of a test. CONCLUSION: Smartphone-assisted home urinalysis enabled remote management of UTI in a high-risk population. Outcomes point to a reduction in UTI complications and hospitalisations.

Urine testing in young febrile children: a risk-benefit analysis.

OBJECTIVE: To assess the relative risks and benefits of 10 potential urine testing strategies (compared with no testing) involving urinalysis and urine culture for children aged 3 to 24 months with fever but no focus of bacterial infection. DESIGN: Decision analysis based on the literature. The 10 testing strategies consist of five pairs; within each pair of strategies, one calls for urinalysis and urine culture of a clean-voided (bag) specimen, and urine culture, and in the other, the urine specimen is sent for culture only if the result of the urinalysis is abnormal. The five pairs differ in selectivity for testing: all children, girls only, temperature > or = 39 degrees C only, fever only (no respiratory or gastrointestinal symptoms), or temperature > or = 40 degrees C only. The results of the decision analysis are expressed as the preventive fraction (the proportion of cases prevented) for end-stage renal disease (ESRD) and hypertension, and as two risk/benefit (RB) ratios: the number of children tested per case of ESRD prevented (RB1), and the number of children with false-positive diagnosis and treatment of urinary tract infection per case of ESRD prevented (RB2). RESULTS: On the basis of the available evidence, none of the testing strategies succeeds in preventing the majority of cases of ESRD and hypertension (preventive fraction = 0.10 to 0.50), and all are associated with high ratios of children tested (RB1 = 4167 to 12,500) and false-positive diagnosis and treatment (RB2 = 563 to 1800) per case of ESRD prevented. A strategy of combined urinalysis and urine culture in children with temperature > or = 39 degrees C is associated with the most favorable RB profile: preventive fraction = 0.45, RB1 = 5556; RB2 = 776. Sensitivity analyses indicate that the relative ranking of the strategies is relatively robust in regard to alterations in the estimates of the sensitivity or specificity of the urinalysis, the relative risk of renal scarring associated with delayed diagnosis and treatment, and the risk of scarring-induced hypertension or ESRD. CONCLUSIONS: Up to 50% of the long-term sequelae of occult urinary tract infections in young febrile children appear preventable by urine testing, but even the most favorable strategies require testing of thousands of children, and unnecessarily treating hundreds, for every case prevented. Our analysis reveals those strategies with more favorable RB profiles and emphasizes the need for rapid and convenient urine tests with much higher sensitivity and specificity or the need for less aggressive management strategies for febrile infants and young children with urinary tract infection.