Pyuria and urine concentration for identifying urinary tract infection in young children

OBJECTIVES: Accuracy of pyuria for urinary tract infection (UTI) varies with urine concentration. Our objective of this study was to determine the optimal white blood cell (WBC) cutoff for UTI in young children at different urine concentrations as measured by urine specific gravity. METHODS: Retrospective cross-sectional study of children,24 months of age evaluated in the emergency department for suspected UTI with paired urinalysis and urine culture during a 6-year period. The primary outcome was positive urine culture result as described in the American Academy of Pediatrics clinical practice guideline culture thresholds. Test characteristics for microscopic pyuria cut points and positive leukocyte esterase (LE) were calculated across 3 urine specific gravity groups: low,1.011, moderate 1.011 to 1.020, and high.1.020. RESULTS: Of the total 24 171 patients analyzed, urine culture result was positive in 2003 (8.3%). Urine was obtained by transurethral in-and-out catheterization in 97.9%. Optimal WBC cutoffs per high-power field (HPF) were 3 (positive likelihood ratio [LR1] 10.5; negative likelihood ratio [LR2] 0.12) at low, 6 (LR1 12; LR2 0.14) at moderate, and 8 (LR1 11.1; LR2 0.35) at high urine concentrations. Likelihood ratios for small positive LE from low to high urine concentrations (LR1 25.2, LR2 0.12; LR1 33.1, LR2 0.15; LR1 37.6, LR2 0.41) remained excellent. CONCLUSIONS: Optimal pyuria cut point in predicting positive urine culture results changes with urine concentration in young children. Pyuria thresholds of 3 WBCs per HPF at low urine concentrations whereas 8 WBCs per HPF at high urine concentrations have optimal predictive value for UTI. Positive LE is a strong predictor of UTI regardless of urine concentration.