(Received October 26, 1972; revision accepted for publication February 18, 1973.)
ADDRESS FOR REPRINTS: (A.M.) Department of Pediatrics, Yale University School of Medicine, 333 Cedar Street, New Haven, Connecticut 06510.
PEDIATRICS, Vol. 52, No. 1, July 1973
21/37
A SURVEY
OF
OFFICE
MANAGEMENT
OF
URINARY
TRACT
INFECTIONS
IN CHILDHOOD
Thomas F. Dolan, Jr., M.D., and Alan Meyers, M.D.
Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
ABSTRACT. Responses to a written questionnaire by family physicians and pediatricians in private practice concerning their evaluation and manage-ment of suspected childhood urinary tract
infec-tions have been compared to the standards
em-ployed by a university pediatric department, which include documentation by culture, radiographic evaluation, and treatment. The survey reveals that
50% of physicians who responded made this
diag-nosis without cultures in the office setting. Criteria
for ordering radiographic studies, choice of anti-biotics, and indications for referral to a urologist
differed from the standards. The implications of
failure to discover correctable genitourinary abnor-malities and of unnecessary drug or hospital utiliza-tion, and the place of peer review and continuing medical education in the private practice setting
are discussed. Pediatrics, 52:21, 1973, URINARY TRACT INFECTIONS, PEER REVIEW, MEDICAL AUDIT,
PRIVATE PRACTICE.
B
ASED on a review of current medicallit-erature,7 textbooks, and the guidelines established by the Yale University Depart-ment of Pediatrics, certain guiding
princi-ples for the optimal work-up and initial
management of suspected urinary tract
in-fections are as follows:
1. A diagnosis of a bacterial urinary tract
infection requires one or more positive
quantitative urine cultures of 100,000 or
more organisms per cubic millimeter in
pure culture. An exception is the presence
of the same organism in pure culture on
re-peated examinations in quantities less than 100,000/cu mm. This is especially true when
pseudomonas or klebsiella are found.
Al-though the finding of bacteria on a fresh
unspun urine examination has been
re-ported1 to correlate with culture results, we
have felt that this examination does not
substitute for a culture. Absence of bacte-ria, in general, should be sufficient to make further work-up for urinary tract infection
unnecessary; although, when the
symptom-atology is extremely suggestive, several
urine cultures may be indicated before
nil-ing out the diagnosis.
2. Lower tract infections cannot be accu-rately differentiated from upper tract
infec-tions on clinical grounds in the usual
pa-tient.
3. Intravenous pyelograms should be ob-tained subsequent to the first proven urinary tract infection in a male, and after either the
first or second infection in a female.
4. Voiding cysturethrograms usually
should be obtained after the first infection
in a male and in recurrent infections in a
female, unless unusual organisms predomi-nate or the female is an infant.
5. Acceptable therapy for a first urinary tract infection in a child is either a
sulfon-amide, ampicillin, or cephalexin for 2 to 6
weeks or an antibiotic selected on the basis of bacterial sensitivity data.
To see how closely actual office
manage-ment coincided with the foregoing
“opti-mal” evaluation, a questionnaire was mailed to all known board-certified pediatricians in
practice (185) and an additional 200 family
physicians practicing in Connecticut. This
questionnaire listed several choices for each
question to reduce the amount of writing.
Questions concerned the criteria used to
di-agnose a urinary tract infection, the
anti-microbial therapy employed, whether
up-per and lower urinary tract disease were
evalua-OFFICE MANAGEMENT OF URINARY INFECTIONS
22/38
TABLE I
DIAGNOSTIC CRITERIA USED FOR MAKING A DIAGNOSIS OF URINARY TRACT INFECTION
Family
Pediatricians CriteriaPractitioners
(%) (%)
History and pyuria alone 25 13 History, pyuria, proteinuria
alone 34 32
Gram stain of urine 1 2
Culture and colony count 4 13
All of the above 35 40
TABLE II
CRITERIA USED FOR ORDERING AN INTRAVENOUS PYELOGRAM
Family Practitioner Pediatrician
Attack Female Male Female Male
(%) (%) (%) (%)
First 6 30 2 78
Second 56 54 80 21
Third 38 16 18 1
TABLE III ANTIBIOTIC THERAPY Family . Pediatricians Drug Practitioners I/o /0)
Sulfonamide 1-3 wk 48 65
Sulfonamide over 3 wk 7 16
Ampicillin 14 10
Nitrofurantoin 10 4
Tetracycline 10 4
Other ii 1
Note: At the time of this questionnaire, cephalexin
was not commercially available.
TABLE IV
ABILITY TO SEPARATE “PYELITIS” FROM “CYSTITIS”
Ansu’er Family
Practitioners Pediatricians
Yes 67 62
No ‘20 29
Sometimes 13 9
tion intravenous pyelography and voiding
cystourethrograms were ordered, and when
referrals to other physicians were made.
Op-portunity was provided to write in other
choices and the form was designed to be
filled in anonymously. Data concerning the
year of graduation from medical school,
speciality training, and the approximate
number of children seen annually having
urinary tract infections were also
col-lected.
RESULTS
Sixty-five percent of board-certified
pedi-atricians and 40% of family physicians
re-sponded to the questionnaire. Six responses
were eliminated because the physician in
question was not currently in practice or
re-stricted his practice to adults. In view of
the anonymity, it was not possible to resur-vey nonrespondents.
Table I lists the criteria used to diagnose a urinary tract infection. There was no sta-tistically significant difference between the
family practitioners and pediatricians;
ap-proximately 50% of the physicians based
the diagnosis of urinary tract infection on
the basis of a urinalysis and a history.
When asked for a definition of pyuria,
there was a large variety of responses,
rang-ing from 2 to 5 white cells per high power
field to more than 30. The majority of phys-icians felt that 11 to 20 cells per high power
field constituted pyuria. There were many
qualifying statements such as “only with
clumps,” and some physicians differentiated the number of cells allowed in boys versus
girls. Other physicians used only spun
urine, not specifying how much was spun
or for how long.
Table II lists the criteria used as a basis
for ordering an intravenous pyelogram. Of
note is the fact that 9% of family
practi-tioners and 10% of pediatricians left this
decision to the judgment of a urologist. A significant number of physicians stated
they did not order an intravenous
pyelo-gram after the first infection. This omission
was most common in first urinary tract
in-fections of males, in whom only 38% of the
un-ARTICLES
23/39
nary tract radiographically and 16% waited
until the third episode.
Antibiotic therapy employed for the
mi-tial treatment of a urinary tract infection (Table III
)
reflects fairly uniform use ofei-then a sulfonamide or ampicillin. Other
drugs mentioned were chioramphenicol, penicillin, mandelamine, and tetracycline.
Two-thirds of the respondents said they
distinguished upper from lower urinary
tract infections prior to radiographic
evalu-ation (Table IV). Many physicians added
qualifying remarks to the effect that they
ordered cultures and radiographic
evalua-tions only if the patient had “pyelitis.”
Pa-tients diagnosed as having “cystitis” were
frequently considered as having a benign
illness requiring no further evaluation.
Indications for referrals to urologists
var-ied widely; they ranged from a history of
urinary tract infections to the need for any
type of laboratory evaluations. More than
50% of the primary physicians referred
pa-tients before documenting bacteriuria and
ordering an intravenous pyelogram. No
sig-nificant difference was noted between
pedi-atricians and family practitioners
concern-ing indications for referral.
Analysis of the data by years after
gradu-ation from medical school failed to reveal
any predictable physician differences in
methods employed to diagnose urinary
tract infections or evaluation criteria.
DISCUSSION
Despite the limitations inherent in a
re-trospective questionnaire, this survey
sug-gests that many primary care physicians are
not utilizing what we defined as proper
guidelines for the management of suspected childhood urinary tract infections. This was most evident in the apparent failure to uti-lize cultures as an essential diagnostic tool.
Although it was not possible to measure
actual performance against stated
perfor-mance of the respondents or to survey
non-respondents, these results agree with our
impression that there is a long delay
be-tween the general acceptance of diagnostic criteria9 and their translation into practice.
Since Pryles and Eliot10 point out that
20% of children with pyuria do not have
bacteriuna and 40% with bacilluria do not
have pyuria, diagnosis of bacterial urinary
tract infection based solely on symptoms
and pyuria is subject to gross error. We do
not know whether the physicians sampled
considered urine cultures unnecessary,
un-important, or impractical in an office
set-ting; certainly calibrated loops, disposable
culture plates, inexpensive incubators, and
commercial kits all make urine cultures in an ambulatory setting feasible.
It is not known whether long-standing,
asymptomatic bacteriuria in children leads
to chronic renal disease. However, it is an
accepted fact that a significant number of children with bacteriuria have surgically correctable abnormalities of the genitouni-nary tract. Delay in arriving at a definitive diagnosis may, therefore, lead to
irrevers-ible pathology. On the other hand, a
mis-taken diagnosis of urinary tract infection
may subject the child to unnecessary
ma-nipulation, radiation, drugs, and hospital-ization.
Because continuing medical education
fails to insure high standards of office
prac-tice, establishment of evaluation criteria
coupled with peer review has been
sug-gested and is being pursued by the
Ameri-can Academy of Pediatrics in association
with the American Academy of Family
Practice and other groups. Brown and UhP
have described an educational program in
an inpatient setting in a community
hospi-tal that hs had a dramatic effect on
physi-cal performance as well as knowledge.
With the establishment of strict criteria for
patient care and a problem-oriented
educa-tional program, they reported a decrease in
inappropriate antibiotic use from 70% to
40%, with concomitant decreases in surgical complications and unnecessary
hysterecto-mies. An innovative program for practicing
physicians in an ambulatory setting based
on peer review and problem oriented
edu-cation and audit should be explored.
REFERENCES
THE THIRTEEN-YEAR-OLD LOUISA MAY ALCOTT WRITES
OF HER WISH FOR A ROOM OF HER OWN
OFFICE MANAGEMENT OF URINARY INFECTIONS
24/40
Pediatric Therapy. Philadelphia: W. B.
Saunders, 1970, p. 568-571.
2. Pryles, C. V.: Infections of the urinary tract.
In Green, M., and Haggerty, R. J., eds.:
Am-bulatory Pediatrics. Philadelphia: W. B.
Saunders, 1968, pp. 921-927.
3. Boichis, H., and Edelmann, C.: Infections of
the urinary and genital. In Barnett, H. ed.: Pediatrics. New York: Appleton-Century-Crofts, 1968, pp. 1391-1398.
4. Rubin, M.: Infections of the urinary tract. In
Nelson, W. E., ed. Textbook of Pediatrics.
Philadelphia: W. B. Saunders, 1964, pp.
1107-1113.
5. North, A. F.: Urinary tract infection in
child-hood. Clin. Ped., 5:729, 1966.
6. Davidson, A. C.: Pediatric urinary tract
infec-tions: A review. Conn. Med., 35:17, 1971. 7. Sanford, J. P.: Management of urinary tract
in-fections. Med. Times, 96:715, 1968. 8. Pryles, C. V., and Steg, N.: Specimens of urine
obtained from young girls by catheter versus voiding. A comparative study of bacterial cultures, gram stains and bacterial counts in
paired specimens. PEDIATRICS, 23:441, 1959.
9. Kass, E. H.: Asymptomatic infections of the
urinary tract. Trans. Assoc. Amer.
Physi-cians, 119:56, 1956.
10. Pryles, C. V., and Eliot, C. R.: Pyuria and
bac-teriuria in infants and children. Amer. J.
Dis. Child., 110:628, 1965.
11. Brown, C. R., and Uhl, H. S. M.: Mandatory
continuing education-sense or nonsense?
JAMA, 213:1660, 1970.
One of Louisa Alcott’s (1832-1888)
strong-est desires as a young adolescent was for a
room of her own. The following is taken from her Journal and was written when she was 13 years old.
Fruitlands
March, 1846,-I have at last got the little room
I have wanted so long, and am very happy about
it. It does me good to be alone, and mother has
made it very pretty and neat for me. My
work-basket and desk are by the window, and my closet is full of dried herbs that smell very nice. The door that opens into the garden will be very pretty in
summer, and I can run off to the woods when I
like.
I have made a plan for my life, as I am in my
teens, and no more a child. I am old for my age, and don’t care much for girl’s things. People think
I’m wild and queer; but mother understands and
helps me. I have not told any one about my plan;
but I’m going to be good. I’ve made so many
resolutions, and written sad notes, and cried over my sins, and it does n’t (sic) seem to do any good! Now I’m going to work really, for I feel a true de-sire to improve, and be a help and conifort, not a care and sorrow, to my dear mother.’
NOTED BY T. E. C., Jn., M.D.
REFERENCE
1. Alcott, L. M.: Her Life, Letters, and Journals,
edited by Cheney, E. D. Boston: Robeits
