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Impact of circumcision status on incidence of anatomic anomalies and bacterial species: A retrospective review of pediatric male UTIs presenting to the Emergency Department
Sarah A. Holzman, MD1, Campbell Grant, MD2, Rebecca Zee, MD3, Bruce M. Sprague, BS3, Md Sohel Rana, MD3, Emily Blum, MD4, H. Gil Rushton, MD3.
1Medstar Georgetown, Washington, DC, USA, 2George Washington University, Washginton, DC, USA, 3Children's National Medical Center, Washington, DC, USA, 4Emory University, Atlanta, GA, USA.

Background:
The American Academy of Pediatrics guidelines recommend delaying voiding cystourethrogram until the second febrile urinary tract infection (UTI). Currently, there is no good clinical indicator to determine which patients would benefit from earlier imaging. Here, we sought to identify clinical and bacteriologic findings that are associated with anatomic anomalies in pediatric males presenting to the Emergency Department (ED) with UTI at our institution.
Methods:
A retrospective review of all urine cultures from our ED between 2006 and 2015 was performed.
Males under 18 years of age with ≥50,000 CFU/mL of Proteus, Klebsiella, Escherichia coli, Staphylococcus, Streptococcus and Enterococcus were included. Clean catch or catheterized specimens were included whereas bagged specimens and specimens from patients on intermittent catheterization were excluded. Ultrasound and cystogram images were reviewed when available. Univariate and multivariable Poisson regression with robust variance was used to calculate and compare prevalence ratios. In adjusted analyses, confounders were selected in the model by significance criteria (p<0.05) or 10% change in estimate criteria. Statistical analysis was performed with Stata software, version 15.1 MP (Stata Corporation, College Station, Texas, USA).
Results:
1585 urine cultures were reviewed and 814 met eligibility criteria including 620 (76.2%) Escherichia coli, 84 (10.3%) Proteus, 55 (6.8%) Klebsiella, 30 (3.7%) Staphylococcus, 13 (1.6%) Enterococcus and 12 (1.5%) Streptococcus. Median age of circumcised males was 2.8 months (IQR: 0.5-8.1) compared to 0.4 months (IQR 0.2-1.8) in uncircumcised males (Mann Whitney U test, p<0.001). After adjusting for age, ethnicity and bacterial species, the prevalence of high grade vesicoureteral reflux (VUR, defined as grades III-V) was 3.9 times higher in circumcised males compared to uncircumcised males (95% CI: 1.7-8.9, p=0.001). Circumcised males had a 3.6 times increased prevalence of high grade hydronephrosis (defined as SFU grades III and IV) compared to uncircumcised males (prevalence ratio: 3.6, 95% CI: 1.2-10.4, p=0.018). Among bacterial pathogens, no Proteus UTI patients had high grade hydronephrosis or VUR. In contrast, Staphylococcus species was found to be an independent predictor of bladder anomalies including high grade VUR and/or high grade hydronephrosis compared to non-Staphylococcal organisms (prevalence ratio 5.4, 95% CI: 2.6-11.2, p<0.001).
Conclusions:
Circumcision status is an independent predictor of genitourinary anomalies in pediatric males with UTI, therefore circumcised males should be considered for early imaging after their first UTI. Furthermore, Staphylococcal infections were associated with an even higher prevalence of high grade hydronephrosis and/or bladder anomalies including high grade VUR. In contrast, none of the Proteus infections were associated with high grade VUR or hydronephrosis making initial observation more appropriate in these patients.


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