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I have been following the UTI discussion with interest and note that
there is a wide divergence of opinion.
 
I think that it would be useful if people would read the June and July
essays by Richard Bukata in Emergency Medical Abstracts and comment on
his recommendations.
 
Alternatively, what about reading the American Academy of Pediatrics
recommendations as developed by the "Subcommittee on urinary tract
infections" and which was published in Pediatrics (vol. 103 Number 4
April 1999) and which is available at
www.pediatrics.org/content/full/103/4/e54
 
I would be interested to hear about alternative points-of-view and why
you disagree with their recommendations.
 
In particular, I would like to know why Richard Bukata has two different
approaches for approaching an UTI in febrile children between 2 months -
2 years. He divides the children into two groups: those that look ill
and those who don't look so ill so as to require immediate antibiotic
therapy for a possible UTI. He does not define what parameters he uses
to make this clinical distinction. He seems to lower his standards when
dealing with children, who do not look sick, and does not mandate C&S of
all cases irrespective of the urinalysis - which he admits does not have
100% sensitivity for  an UTI (option number 2). In fact, he suggests
that if the urinalysis on urine obtained by the most convenient means
(urine bag specimen) does not suggest an UTI => do not culture the urine
and do not treat with antibiotics. I do not understand this rationale of
dividing febrile children with a possible UTI into two groups depending
on how they look! On what scientific basis can you a priori decide which
sub-group of  febrile pre-verbal children may have a UTI based on their
clinical appearance => and therefore only selectively culture the one
group?
 
Richard Bukata also comments on the article by Alejandro Hoberman and
Ellen Wald (Ped Infect Dis Journal 16 (1) January 1999) who demonstrate
that an urine dipstick does not have sufficient sensitivity (< ~ 70%) to
exclude an UTI and that a C&S is routinely warranted; or the combination
of an enhanced urinalysis on unspun urine + gram stain of unspun urine,
which has greater sensitivity (~ 85%).
 
 
Jeff
 
To those of you who are interested in adult EM => you can visit my
website at http://homestead.com/emguidemaps/JeffMannEMguidemaps.html =>
I would appreciate any positive commentary or criticism that can make my
guidemaps more accurate and more useful.
 
For more information, send mail to [log in to unmask] with the message: info PED-EM-L
The URL for the PED-EM-L Web Page is:
  http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html