1. Rule Out UTI

2. Shaikh N et al. Prevalence of urinary tract infections in childhood. A meta- analysis. Ped Infect Dis J 2008

3. Prevalence of Disease - Girls 3 – 6 mos: 5% or 1/20 6 – 12 mos: 8% or 1/12 12 – 24 mos: 2% or 1/50

4. Prevalence - Males Uncirc: 3 – 12 mos: 5-7% or 1/16- 1/20 Circ: 3 – 12 mos: 2% or 1/50

5. Reducing the number of tests by risk stratification

6. Marc Gorelick, Kathy Shaw, A. Hoberman Clinical decision rule to identify febrile young girls at risk for urinary tract infection. Arch Pediatr Adolesc Med 2000. Validation of a decision rule identifying febrile young girls at high risk for urinary tract infection. Ped Emerg Care 2003.

7. Decision Rule? – No Decision Guideline? - Yes

8. Decision Guideline Excludes: Kids with obvious bacterial cause of fever – meningitis, pneumonia, strep pharyngitis Kids with definitive viral dx – Varicella, Coxsackie, Herpetic stomatitis Kids with HSP, Kawasaki’s

9. Girls < 2 years 2 or more of: »T > 39 o C »white »age < 12 months »no other source of fever »fever > 2 days past history of UTI symptoms specific to UTI

10. 13 m Hisp female with 103 fever Fever for one day URI on exam No hx of UTI or UTI sx = No need to do U/A

11. 9 m Cauc female with 101.5 Fever for 3 days No URI or AGE No hx of UTI or UTI sx = Get a urine

12. Boys < 1 year uncircumcised, or age < 6 months and no other source of fever past history of UTI symptoms specific to UTI

13. Diagnostic Testing Urine dipstick for LE, Nitrite

14. What is a positive? 1+ LE or greater + Nitrite whether or not LE is positive

15. Dip - Diagnostic Accuracy: Sensitivity ~ 85% Specificity ~ 90%

16. After dip, what is chance of disease? Dip negative – if chance of UTI was ~ 1/20, now ~ 1/120 Dip positive – if chance of UTI was ~ 1/20, now between 1/2 to 1/3 chance

17. Eliminate the Gram Stain in Kids Over 3 months

18. Cystitis and Urine Culturing Cystitis must be clearly defined

19. Considering Eliminating Culture Dysuria, frequency. Age > 3 years No evidence of upper tract disease – fever, back pain, vomiting, abd pain. No UTI in the last year LE and Nitrite Positive No chance of Herpes Labialis or STD