Can Diagnostic and Imaging Recommendations from the 2011 AAP UTI Guidelines be Applied to Infants <2 Months of Age?
Ryan F. Walton, B.S., Rachel Shannon, MPH, James Rague, MD, David Chu, MD, MSCE, Ilina Rosoklija, MPH, Laura Carter, MD, Emilie K. Johnson, MD, MPH.
Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
BACKGROUND: In 2011, the American Academy of Pediatrics (AAP) published guidelines focused on the diagnosis and management of children 2-24-months-old with an initial febrile urinary tract infection (fUTI). Available data were described as insufficient to determine whether evidence from studies of 2-to-24-month-olds applies to those <2-months-old, so they were excluded. This study aimed to: 1) compare parameters between patients <2-months-old and 2-to-24-months-old hospitalized with fUTI, and 2) appraise whether diagnostic and imaging recommendations of these guidelines are applicable to those <2-months-old.METHODS: A retrospective cross-sectional study of children ages 0-24-months hospitalized with a fUTI from 2016-2018 was conducted. Univariate and bivariate statistics were used to compare demographics, and diagnostic, imaging, and healthcare utilization outcomes of the <2 and 2-to-24-month age groups.RESULTS: Overall, 137 patients were included (median age 70 days). Most were male (55.5%), Hispanic/Latino (53.3%) and publicly insured (58.4%). There were no demographic differences between groups, except children <2-months-old were more frequently male (71.2 vs 43.6%, p=0.002). Most presented with their first fUTI (89.8%) and most males were uncircumcised (92.1%) with phimosis (77.6%). When compared with children 2-24-months-old, those <2-months-old had greater lengths of stay (median: 3 vs 2 days, p<0.001), but a lower fever duration (median: 2 vs 3 days, p<0.001), maximum temperature (median: 101.8 vs 103.2 degrees Fahrenheit, p<0.001), and white blood cell count (WBC) (median: 12.2 vs 16.2 K/µL, p=0.005). There were no significant differences in urinalysis results for bacteriuria (82.1 vs 70.1%, p=0.196), leukocytes (89.3 vs 84.4%, p=0.772), nitrites (28.6 vs 32.5%, p=0.291), and WBC >3 (89.3 vs 75.3%, p=0.165). There were also no differences in urine culture results between groups (Table 2). Overall, 64.2% of the cohort was recommended to undergo and 51.1% underwent a voiding cystourethrography (VCUG) with those <2-months more likely to receive a recommendation (76.3 vs 55.1%, p=0.017) and obtain a VCUG (64.4 vs 41.0%, p=0.011). There were no differences in imaging results between groups (Table 3). Only 36.8% of males had a circumcision recommended with no difference between groups (35.7 vs 38.2%, p=1.00), but those <2-months-old more frequently had a circumcision performed (19.0 vs 2.9%, p=0.04). There was no difference between groups regarding UTI recurrence within 1 year (13.6 vs 14.1%), 90-day readmission (6.8 vs 6.4%), or 90-day emergency department revisit (22.0 vs 20.5%) (all p=1.00). CONCLUSION: Children <2-months-old hospitalized with fUTI had similar urinalysis, microbial and imaging results compared to those 2-24-months-old. Management and healthcare utilization outcomes were also relatively similar, excluding VCUG utilization. These data support applying imaging and diagnostic recommendations from the 2011 AAP Guidelines to those <2-months-old.
| Total (N = 137) | <2 Months (N = 59) | 2-24 Months (N = 78) | P-Value§ | |
| Age (Days)† Mean, Median [Range] | 122.8, 70 [7 - 594] | 32.29, 34 [7 - 60] | 191.3, 120, [63 - 594] | <0.001 |
| Median Household Income by Zip Code (dollars)† | $66,602.00, $60,073.00 [$22,992.00 - $166,262.00] | $65,181.00, $60,073.00[$27,262.00 - $135,146.00] | $67,676.00, $60,073.00 [$22,992.00 - $166,262.00] | 0.945 |
| Sex | 0.002 | |||
| Female | 61 (44.5%) | 17 (28.8%) | 44 (56.4%) | |
| Male | 76 (55.5%) | 42 (71.2%) | 34 (43.6%) | |
| Race* | 0.644 | |||
| White | 44 (32.1%) | 23 (39.0%) | 21 (27.0%) | |
| Black | 8 (5.8%) | 3 (5.1%) | 5 (6.4%) | |
| Asian | 7 (5.0%) | 2 (3.4%) | 5 (6.4%) | |
| Other | 75 (54.7%) | 30 (50.8%) | 45 (57.7%) | |
| Refused/Unknown | 3 (2.2%) | 1 (1.7%) | 2 (2.6%) | |
| Ethnicity* | 0.832 | |||
| Hispanic/Latino | 73 (53.3%) | 30 (50.8%) | 43 (55.1%) | |
| Non-Hispanic/Latino | 61 (44.5%) | 28 (47.5%) | 33 (42.3%) | |
| Unknown | 3 (2.2%) | 1 (1.7%) | 2 (2.6%) | |
| Insurance* | 0.214 | |||
| Private | 55 (40.1%) | 26 (44.1%) | 29 (37.2%) | |
| Public | 80 (58.4%) | 31 (52.5%) | 49 (62.8%) | |
| Other (Tricare = Military) | 1 (0.7%) | 1 (1.7%) | 0 (0.0%) | |
| Unknown | 1 (0.7%) | 1 (1.7%) | 0 (0.0%) | |
| * Fisher Exact test; † Mann-Whitney U test; § P-Value from comparison of two columns to the left. | ||||
| Total (N = 137) | <2 Months (N = 59) | 2-24 Months (N = 78) | P-Value§ | |
| Source of Urine Culture* | 0.743 | |||
| Bagged | 6 (4.3%) | 2 (3.4%) | 4 (5.1%) | |
| Catheterized | 115 (83.9%) | 52 (88.1%) | 63 (80.8%) | |
| Clean Catch Urine | 8 (5.8%) | 3 (5.1%) | 5 (6.4%) | |
| Unknown | 8 (5.8%) | 2 (3.4%) | 6 (7.7%) | |
| Organisms*a | 0.799 | |||
| E. Coli | 109 (79.6%) | 48 (78.7%) | 61 (75.3%) | |
| Klebsiella | 11 (8.0%) | 3 (4.9%) | 8 (9.9%) | |
| Enterococcus | 7 (5.1%) | 4 (6.6%) | 3 (3.7%) | |
| Citrobacter | 5 (3.6%) | 2 (3.3%) | 3 (3.7%) | |
| Otherb | 10 (7.3%) | 4 (6.6%) | 6 (7.4%) | |
| Organism CFU Count*a | 0.512 | |||
| >1k - 10k | 5 (3.5%) | 3 (4.9%) | 2 (2.4%) | |
| >10k - 25k | 9 (6.3%) | 2 (3.3%) | 7 (8.4%) | |
| >25k - 50k | 7 (4.9%) | 4 (6.6%) | 4 (4.8%) | |
| >50k - 100k | 44 (30.6%) | 21 (34.4%) | 22 (26.5%) | |
| >100k | 77 (53.5%) | 31 (50.8%) | 46 (55.4%) | |
| Unknown | 2 (1.4%) | 0 (0.0%) | 2 (2.4%) | |
| Antibiotic Resistance Patterns | ||||
| Ampicillin | 66 (48.2%) | 29 (49.2%) | 37 (47.4%) | 0.979 |
| Ampicillin/Sulbactam | 41 (29.9%) | 18 (30.5%) | 23 (29.5%) | 1 |
| Otherc | 38 (27.7%) | 17 (28.8%) | 22 (26.9%) | 0.959 |
| Ancef | 35 (25.5%) | 13 (22.0%) | 22 (28.2%) | 0.534 |
| Bactrim | 32 (23.3%) | 16 (27.1%) | 16 (20.5%) | 0.483 |
| Not Available | 11 (8.0%) | 3 (5.1%) | 8 (10.3%) | 0.350 |
| Ceftriaxone* | 8 (5.8%) | 5 (8.5%) | 3 (3.8%) | 0.289 |
| Cipro* | 8 (5.8%) | 3 (5.1%) | 5 (6.4%) | 1 |
| Gentamicin* | 7 (5.1%) | 2 (3.4%) | 5 (6.4%) | 0.699 |
| Nitrofurantoin* | 3 (2.2%) | 0 (0.0%) | 3 (3.8%) | 0.259 |
| Amoxicillin* | 3 (2.2%) | 1 (1.7%) | 2 (2.6%) | 1 |
| Keflex* | 1 (0.7%) | 1 (1.7%) | 0 (0.0%) | 0.431 |
| Tazo* | 1 (0.7%) | 1 (1.7%) | 0 (0.0%) | 0.431 |
| Vanco* | 1 (0.7%) | 0 (0.0%) | 1 (1.3%) | 1 |
| Amikacin* | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 1 |
| Omnicef* | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 1 |
| Cefixime* | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 1 |
| Clindamycin* | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 1 |
| Fluconazole* | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 1 |
| * Fisher Exact Test; a Greater than 100% as some patients may have had multiple organisms on urine culture; b Staph Aureus (N = 3), Non-speciated Gram Negative (N = 2), Gardenerella Vaginalis (N = 1), Pseudomonas, (N = 1), Enterobacter (N = 1), Enterobacter Cloacae (N = 1), Streptococcus Anginosus (N = 1) and unknown (N = 2); c Amoxicillin/K Clavanate (N = 10), Tobramycin (N = 9), Aztreonam (N = 9), Cefuroxime (N = 9), Ceftazidime (N = 8), Cefotaxime (N = 7), Cefepime (N = 7), Cephalothin (N = 7), Cefuroxime (Oral) (N = 6), Levofloxacin (N = 5), Cefoxitin (N = 6), Cefuroxime (Parenteral) (N = 3), Tetracycline (N = 3), Gentamicin (N = 2), Penicillin (N = 1), Rifampin (N = 1), Penicillin G (N = 1); § P-Value from comparison of two columns to the left. | ||||
| Total (N = 137) | <2 Months (N = 59) | 2-24 Months (N = 78) | P-Value§ | |
| Renal Bladder Ultrasound (RBUS) ordered at Index Encounter | ||||
| Hydronephrosis on RBUS | 83 (61.5%) | 38 (65.5%) | 45 (58.4%) | 0.511 |
| Hydronephrosis Laterality on RBUS | 0.289 | |||
| None | 52 (38.5%) | 20 (34.5%) | 32 (41.6%) | |
| Unilateral | 48 (35.6%) | 19 (32.8%) | 29 (37.7%) | |
| Bilateral | 35 (25.9%) | 19 (32.8%) | 16 (20.8%) | |
| Hydroureter Laterality* | 0.254 | |||
| None | 119 (88.1%) | 54 (93.1%) | 65 (84.4%) | |
| Unilateral | 13 (9.6%) | 4 (6.9%) | 9 (11.7%) | |
| Bilateral | 3 (2.2%) | 0 (0.0%) | 3 (3.9%) | |
| Hydronephrosis Grade*a | 0.692 | |||
| None | 52 (38.5%) | 20 (34.5%) | 32 (41.6%) | |
| Trace/Minimal | 25 (18.5%) | 12 (20.7%) | 13 (16.9%) | |
| Mild | 53 (39.3%) | 25 (43.1%) | 28 (36.4%) | |
| Moderate | 5 (3.7%) | 1 (1.7%) | 4 (5.2%) | |
| Severe | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | |
| VCUG ordered at Index Encounter | ||||
| Vesicoureteral Reflux (VUR) on VCUG | 16 (22.8%) | 9 (23.7%) | 7 (21.9%) | 1 |
| VUR Laterality* | 0.921 | |||
| None | 54 (77.2%) | 29 (76.3%) | 25 (78.1%) | |
| Unilateral | 8 (11.4%) | 4 (10.5%) | 4 (12.5%) | |
| Bilateral | 8 (11.4%) | 5 (13.2%) | 3 (9.4%) | |
| VUR Grade*a | 0.987 | |||
| None | 54 (77.1%) | 29 (76.3%) | 25 (78.1%) | |
| 1 | 1 (1.4%) | 0 (0.0%) | 1 (3.1%) | |
| 2 | 4 (5.7%) | 2 (5.3%) | 2 (6.3%) | |
| 3 | 5 (7.1%) | 3 (7.9%) | 2 (6.3%) | |
| 4 | 5 (7.1%) | 3 (7.9%) | 2 (6.3%) | |
| 5 | 1 (1.4%) | 1 (2.6%) | 0 (0.0%) | |
| * Fisher Exact test; a Highest grading on either kidney was used as overall grade for hydronephrosis on RBUS and vesicoureteral reflux on VCUG; § P-Value from comparison of two columns to the left. | ||||
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