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How best to diagnose urinary tract infection in preschool children in primary care?

BMJ 2011; 343 doi: (Published 25 October 2011) Cite this as: BMJ 2011;343:d6316
  1. Alastair D Hay, reader in primary healthcare1,
  2. Penny Whiting, senior research fellow2,
  3. Christopher C Butler, professor of primary care medicine3
  1. 1Academic Unit of Primary Health Care, NIHR National School for Primary Care Research, School of Social and Community Medicine, University of Bristol, Bristol BS8 2PS, UK
  2. 2School of Social and Community Medicine, University of Bristol, Bristol, UK
  3. 3Department of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK
  1. Correspondence to: alastair.hay{at}
  • Accepted 20 September 2011

Accurate and timely diagnosis of urinary tract infection (UTI) in young children presenting to primary care is important because appropriate treatment may alleviate suffering and help prevent long term sequelae such as renal scarring, poor renal growth, recurrent pyelonephritis, impaired glomerular function, hypertension, end stage renal disease, and pre-eclampsia.1 2 The prevalence of renal scarring in the general population is unknown, but a systematic review of studies, largely conducted in secondary care, showed 15% of children with an initial episode of UTI had evidence of renal scarring on follow-up dimercaptosuccinic acid (DMSA) scanning, and there was an 8% incidence of UTI recurrence per year.3

Among consultations for illness episodes in children aged under 5 years in the UK, approximately 40% comprise infectious diseases and respiratory episodes, while about 10% of presentations comprise non-specific symptoms. Thus identifying which children have a significant UTI (which often also presents with non-specific symptoms) is a key challenge for primary care clinicians.

The diagnosis is further hampered because young children cannot clearly articulate symptoms; when children wear nappies, parents are not aware of the classic dysuria and frequency symptoms as experienced by adults; and obtaining an adequate urine sample can be frustrating, time consuming, and costly.

The precise prevalence of UTI among all acutely unwell children presenting to primary care is unclear. One systematic review of 10 studies, eight of which were conducted in hospital emergency departments, one in US paediatricians’ offices, and one in an army medical centre, estimated UTI prevalence at 7%.4 A large Australian emergency department study published in 2010 found a prevalence of 3.4% in children presenting with a febrile illness.5 We identified only one small exploratory study conducted in general practitioner/family physician practices, which found a prevalence of 4%.6

It is not surprising then that …

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