Also, the cost effective analyses is only a short term one. It does not
factor in the true endpoint which is prevention of or incidence of long term
effects of a "pyelonephritis" i.e. nephropathy, HTN. All the hype about UTI
is related to the prevention of this outcome One would be reluctant to
implement any screening program without a long term cost effectiveness
study. I believe they do point this out in the article.
Incidentally, UTI without pyuria may not have the same significance as with.
[Hoberman et al. Ped Res. 1995: 37; 138A] I believe it is more interesting
to see not just positive cultures but those with perfusion abnormalities on
renal scan (as a marker of pyelonephritis) and correlate this with the
various screening tests.
Moreover, I thought the definition of UTI of > 10,000 CFU/m/ was too low a
threshold on a cath specimen. Prior studies have used 50,000. Were they
detecting more "colonizations" than UTI's? I would like to see a breakdown
of how many of the positive UC had colony counts > 50k or 100k?
I agree with Dr. Fisher that not defining your inclusion criteria in the
study of febrile infants will impact on pre-test probability of UTI and
hence indirectly on the post test probability of a positive urine culture.
To give you an example: If a 4 month old white girl with FWLS, T = 104 and
TLC of 20k had an enhanced UA done, her pre-test probability of UTI is high.
The likelihood of a positive UC in her is much greater than say a 9 month
old circumcised male with a temp of 104 and no source. This could falsely
enhance the sensitivity of the enhanced UA. (reported as the highest
compared to a dip and routine UA microscopy for pyuria). Remember a test is
only as good as the clinical situation it is used in !!
[Jay Pershad, M.D.]
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