AAP guideline concordance for diagnosis of urinary tract infections (UTI) in febrile children with congenital anomalies of the kidney and urinary tract (CAKUT): a multi-center cohort study
Ermias Araia, BA1, Michael Tchou, MD1, Marguerite Korber, NP1, Jennifer Pyrazanowski, MSPH1, Carter Sevick, MS1, Gemma Beltran, BS1, Victor Trevisanut, BS1, Catherine Forster, MD2, Sowdhamini S. Wallace, MD3, Vijaya Vemulakonda, MD, JD1.
1Pediatric Urology Research Enterprise (PURE), Department of Pediatric Urology, Children's Hospital Colorado, Aurora, CO, USA; Division of Urology, Department of Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, CO, Aurora, CO, USA, 2UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA, 3Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, USA.
BACKGROUND: In 2011 the American Academy of Pediatrics (AAP) outlined the diagnostic criteria for urinary tract infections (UTIs) in febrile children 2 to 24 months old. While these recommendations exist for children with normal anatomy of the urinary tract, little is known about the criteria used to diagnose UTIs in children with congenital anomalies of the kidney and urinary tract (CAKUT) and whether the criteria are being extrapolated to this population. The study aimed to assess the concordance of the AAP guidelines in diagnosing UTI in febrile children with CAKUT.
Methods: We conducted a multicenter retrospective cohort study of children 0-17 in six children’s hospitals across the United States between 1/1/2018- 12/31/2019. Additionally, we reviewed the subset of patients between 2 months and 24 months. The primary outcome of the study, concordance with AAP diagnostic approach, was defined as: presence of ≥50,000CFU/mL of a uropathogen in an appropriately collected urine specimen. Bag specimens were excluded. Univariable analyses examined clinically relevant variables affecting concordance with AAP guidelines (Table 1). Pearson’s chi-square test was used for categorical variables and the Wilcoxon rank sum test for continuous. A multivariable logistic regression model was then developed to identify independent variables influencing AAP guideline concordance (Table 2). Inclusion criteria in our model was based on clinical judgement and statistical significance (p<0.05).
Results: 65.9% of included children under age 18 (n=511) met UTI diagnostic criteria concordant with AAP guidelines. Univariable analysis showed strong evidence gender had an effect on the likelihood of concordance with AAP guidelines (p<0.001). There was moderately strong evidence CAKUT diagnosis and presence of neurogenic bladder had an effect on likelihood of concordance with guidelines (P = 0.022 and 0.013, respectively). 67.3% of patients 2 months to 2 years (n= 168) met concordance with AAP guideline. There was strong evidence gender had an effect on likelihood of concordance (p = 0.008). A greater proportion of females than males had a diagnosis of UTI in concordance with AAP guidelines. Findings in multivariable logistic regression analysis were consistent showing strong evidence gender had an effect on concordance with guidelines (p = 0.0053). Concordance with AAP guidelines was 37% less likely in males than females (OR = 0.37, 95% CI = 0.18-0.74). There was little evidence of concordance with AAP guidelines for CAKUT diagnosis, neurogenic bladder, presence of catheterization, site of the visit, number of ED visits, and vesicostomy (P = 0.42, 0.34, 0.28, 0.52, 0.84, 0.68, respectively).CONCLUSIONS: The majority of children (65-67%) with CAKUT met UTI diagnostic criteria concordant with the AAP guideline. The children without concordance to the guideline had lower urine culture counts. Further studies are needed to delineate the best diagnostic approach of UTI in this population.
| Characteristic | Total | AAP concordant | AAP discordant | p-value |
| All ages (< 18years) | 100% (N= 511) | 65.9% (N = 337) | 34.1% (N = 174) | |
| Gender | Male = 41.3% Female = 58.7% | Male = 55.5% Female = 73.3% | Male = 44.5% Female = 26.7% | <0.001 |
| CAKUT Diagnosis | Bladder lesions = 40.8% Renal Dysplasia = 3.5% Upper Tract Dilation = 24.9% Other = 30.8% | Bladder lesions = 72.1% Renal Dysplasia = 50% Upper Tract Dilation = 57.5% Other = 66.2% | Bladder lesions = 27.9% Renal Dysplasia = 50% Upper Tract Dilation = 42.5% Other = 33.8% | 0.022 |
| Neurogenic Bladder | No = 56.8% Yes = 43.2% | No = 61.4% Yes = 71.9% | No = 38.6% Yes = 28.1% | 0.013 |
| Patients 2 - 24mo | 100% (N = 168) | 67.3% (N = 113) | 32.7% (N = 55) | |
| Gender | Male = 35.1%Female = 64.9% | Male = 54.2%Female = 74.3% | Male = 45.8%Female = 25.7% | 0.008 |
| CAKUT Diagnosis | Bladder lesions = 25.0% Renal Dysplasia = 4.8% Upper Tract Dilation = 35.7% Other = 34.5% | Bladder lesions = 69% Renal Dysplasia = 62.5% Upper Tract Dilation = 60% Other = 74.1% | Bladder lesions = 31.0% Renal Dysplasia = 37.5% Upper Tract Dilation = 40% Other = 25.9% | 0.42 |
| Neurogenic Bladder | No = 77.4%Yes = 22.6% | No = 65.4%Yes = 73.7% | No = 34.6%Yes = 26.3% | 0.34 |
| Effect | Odds Ratio | 95% Lower Confidence Limit | 95% UpperConfidence Limit | Parameter P-value | Joine P-Value |
| Catheterization | 2.03 | 0.74 | 5.58 | 0.1677 | 0.1548 |
| Multiple ED visits | 0.80 | 0.39 | 1.67 | 0.5546 | 0.5530 |
| Site of Study | Site A = 1.02Site B = 1.00Site C =0.32Site D = 0.44Site E = 0.73Site F =0.76 | Site A = 0.26 Site B = 1.00 Site C =0.10 Site D = 0.16 Site E = 0.17 Site F =0.27 | Site A = 3.95 Site B = 1.00 Site C =1.03SSite D = 1.18 Site E = 3.08 Site F =2.13 | Site A = 0.9742 Site B = 1.00 Site C =0.0552 Site D = 0.1026 Site E = 0.6702 Site F =0.6016 | 0.3341 |
| Gender | Male = 0.37 Female = 1.00 | Male = 0.18 Female = 1.00 | Male =0.74 Female = 1.00 | 0.0053 | 0.0048 |
| Age | 0.64 | 0.34 | 1.23 | 0.1829 | 0.1821 |
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