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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/L, 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.

Table 1. Demographics
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
Sex0.002
Female61 (44.5%)17 (28.8%)44 (56.4%)
Male76 (55.5%)42 (71.2%)34 (43.6%)
Race*0.644
White44 (32.1%)23 (39.0%)21 (27.0%)
Black8 (5.8%)3 (5.1%)5 (6.4%)
Asian7 (5.0%)2 (3.4%)5 (6.4%)
Other75 (54.7%)30 (50.8%)45 (57.7%)
Refused/Unknown3 (2.2%)1 (1.7%)2 (2.6%)
Ethnicity*0.832
Hispanic/Latino73 (53.3%)30 (50.8%)43 (55.1%)
Non-Hispanic/Latino61 (44.5%)28 (47.5%)33 (42.3%)
Unknown3 (2.2%)1 (1.7%)2 (2.6%)
Insurance*0.214
Private55 (40.1%)26 (44.1%)29 (37.2%)
Public80 (58.4%)31 (52.5%)49 (62.8%)
Other (Tricare = Military)1 (0.7%)1 (1.7%)0 (0.0%)
Unknown1 (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.

Table 2. Urine Culture Results
Total (N = 137)<2 Months (N = 59)2-24 Months (N = 78)P-Value
Source of Urine Culture*0.743
Bagged6 (4.3%)2 (3.4%)4 (5.1%)
Catheterized115 (83.9%)52 (88.1%)63 (80.8%)
Clean Catch Urine8 (5.8%)3 (5.1%)5 (6.4%)
Unknown8 (5.8%)2 (3.4%)6 (7.7%)
Organisms*a0.799
E. Coli109 (79.6%)48 (78.7%)61 (75.3%)
Klebsiella11 (8.0%)3 (4.9%)8 (9.9%)
Enterococcus7 (5.1%)4 (6.6%)3 (3.7%)
Citrobacter5 (3.6%)2 (3.3%)3 (3.7%)
Otherb10 (7.3%)4 (6.6%)6 (7.4%)
Organism CFU Count*a0.512
>1k - 10k5 (3.5%)3 (4.9%)2 (2.4%)
>10k - 25k9 (6.3%)2 (3.3%)7 (8.4%)
>25k - 50k7 (4.9%)4 (6.6%)4 (4.8%)
>50k - 100k44 (30.6%)21 (34.4%)22 (26.5%)
>100k77 (53.5%)31 (50.8%)46 (55.4%)
Unknown2 (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
Otherc38 (27.7%)17 (28.8%)22 (26.9%)0.959
Ancef35 (25.5%)13 (22.0%)22 (28.2%)0.534
Bactrim32 (23.3%)16 (27.1%)16 (20.5%)0.483
Not Available11 (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.

Table 3. Imaging Utilization and Results
Total (N = 137)<2 Months (N = 59)2-24 Months (N = 78)P-Value
Renal Bladder Ultrasound (RBUS) ordered at Index Encounter
Hydronephrosis on RBUS83 (61.5%)38 (65.5%)45 (58.4%)0.511
Hydronephrosis Laterality on RBUS0.289
None52 (38.5%)20 (34.5%)32 (41.6%)
Unilateral48 (35.6%)19 (32.8%)29 (37.7%)
Bilateral35 (25.9%)19 (32.8%)16 (20.8%)
Hydroureter Laterality*0.254
None119 (88.1%)54 (93.1%)65 (84.4%)
Unilateral13 (9.6%)4 (6.9%)9 (11.7%)
Bilateral3 (2.2%)0 (0.0%)3 (3.9%)
Hydronephrosis Grade*a0.692
None52 (38.5%)20 (34.5%)32 (41.6%)
Trace/Minimal25 (18.5%)12 (20.7%)13 (16.9%)
Mild53 (39.3%)25 (43.1%)28 (36.4%)
Moderate5 (3.7%)1 (1.7%)4 (5.2%)
Severe0 (0.0%)0 (0.0%)0 (0.0%)
VCUG ordered at Index Encounter
Vesicoureteral Reflux (VUR) on VCUG16 (22.8%)9 (23.7%)7 (21.9%)1
VUR Laterality*0.921
None54 (77.2%)29 (76.3%)25 (78.1%)
Unilateral8 (11.4%)4 (10.5%)4 (12.5%)
Bilateral8 (11.4%)5 (13.2%)3 (9.4%)
VUR Grade*a0.987
None54 (77.1%)29 (76.3%)25 (78.1%)
11 (1.4%)0 (0.0%)1 (3.1%)
24 (5.7%)2 (5.3%)2 (6.3%)
35 (7.1%)3 (7.9%)2 (6.3%)
45 (7.1%)3 (7.9%)2 (6.3%)
51 (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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