Adherence to recommendations in the diagnosis of urinary tract infection: a multicenter study

Introduction: pediatric urinary tract infection (UTI) should be diagnosed based on compatible symptoms and a positive urine culture obtained using an appropriate technique, although diagnostic errors are common.

Objective: to analyze diagnostic inadequacy in UTI according to the recommendations of the 2019 Spanish guideline.

Material and methods: a prospective, multicenter observational study was conducted in Spain between October 2019 and December 2020. A total of 206 primary care pediatricians recorded episodes of suspected UTI in their assigned patients.

Results: of the 1506 recorded episodes, 1402 were valid: 1212 (86.4%) were adequately diagnosed and 190 (13.6%) were inadequate (p<0.001). Causes of inadequacy included urine culture from an inappropriate sample (37.4%), diagnosis without urine culture (31.6%), incorrect interpretation of CFU/ml (26.8%), and underdiagnosis (4.2%). The use of urine collection bags in children under two years, particularly in primary care compared with hospital emergency departments (66.7% vs 21.7%; p=0.005), and the absence of urine culture in children aged six years or older compared with those aged two to five years (33.9% vs 66.1%; p=0.015) were associated with higher inadequacy. Hematuria (4.7% vs 11.1%; p=0.001), weight loss (2.4% vs 5.8%; p=0.016), and leukocyte esterase (42.8% vs 53.6%; p=0.009) were also associated with greater diagnostic error. Follow-up urine cultures were more frequent in inadequately diagnosed cases (39.0% vs 26.5%; p=0.002), and 23.6% of antibiotic treatments were unnecessarily maintained.

Conclusions: a total of 13.6% of suspected UTI did not meet diagnostic recommendations, resulting in 23.6% of unnecessary antibiotic treatments. These findings underscore the need to strengthen evidence-based practices, particularly regarding urine sample collection, microbiological confirmation, and interpretation of culture results.