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To Treat or Not to Treat: Incidental Abnormal Urinalysis in Asymptomatic Pediatric Populations and Its Predictive Value for Urinary Tract Infection Development After Voiding Cystourethrogram
Albert S T Lee, DO, PharmD1, Nora Broadwell, MD2, Alexandra Sigel, MD2, Catherine Nguyen, MD3.
1UC Davis Health, Sacramento, CA, USA, 2Texas Childrens Hospital, Houston, TX, USA, 3Kaiser Permanente, Los Angeles, CA, USA.
BACKGROUND: Routine urinalysis (UA) in patients who are asymptomatic or presenting with symptoms unrelated to the urinary tract promotes unnecessary antibiotic use and drives antimicrobial resistance. Despite its clinical prevalence, the natural history of an incidental abnormal UA remains poorly understood. We aimed to determine the prevalence of abnormal UA in a large, asymptomatic pediatric cohort and evaluate its predictive value for the development of a true, symptomatic urinary tract infection (UTI) following a voiding cystourethrogram (VCUG).
METHODS: We retrospectively reviewed asymptomatic pediatric patients who underwent VCUG between 2017 and 2022. A UA and urine culture (UCx) were obtained routinely during all VCUG catheter placements. A symptomatic UTI was defined as a positive UCx with the development of lower urinary tract symptoms or fever within 14 days of the study. Multivariable regression was used to determine the predictive value of UA parameters for post-procedure symptomatic UTI.
RESULTS: A total of 999 asymptomatic patients were evaluated. While 43.3% (433/999) demonstrated an abnormal UA (positive WBC, leukocyte esterase [LE], or nitrites) and 28.2% (282/999) had a positive UCx, only 5.2% (52/999) ultimately developed a symptomatic UTI post-VCUG. On regression analysis, an abnormal UA significantly correlated with a positive culture but was non-predictive of the development of symptomatic UTI, even after genitourinary tract manipulation (p=0.524). Conversely, the absence of a WBC count on urinalysis, negative nitrites, and the absence of LE activity were all significantly associated with a negative urine culture (p<0.001). Among those with >100 WBC/hpf, 82.8% (53/64) had a positive culture vs. only 8.3% (39/469) with a negative WBC count (p<0.001). For nitrite-positive patients, 91.6% (109/119) had a positive culture vs. only 19.5% (172/880) of nitrite-negative patients (p<0.001). At 3+ LE levels, 77.6% (90/116) had positive cultures vs. 10.2% (71/697) for negative levels (p=0.004). However, none of these thresholds predicted progression to a symptomatic UTI.
CONCLUSIONS: Nearly half of asymptomatic pediatric patients undergoing VCUG present with an abnormal UA, yet only 5% develop UTI after genitourinary tract manipulation. The results of our study strongly advise against routine screening UAs in patients who are asymptomatic or presenting with symptoms unrelated to the urinary tract.
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