The New American Academy of Pediatrics Urinary Tract Infection Guideline

This issue of Pediatrics includes a long-awaited update1 of the American Academy of Pediatrics (AAP) 1999 urinary tract infection (UTI) practice parameter.2 The new guideline is accompanied by a technical report3 that provides a comprehensive literature review and also a new meta-analysis, for which the authors obtained individual-level data from investigators. The result is an exceptionally evidence-based guideline that differs in important ways from the 1999 guideline and sets a high standard for transparency and scholarship. The guideline and technical report address a logical sequence of questions that arise clinically, including (1) Which children should have their urine tested? (2) How should the sample be obtained? (3) How should UTIs be treated? (4) What imaging and follow-up are recommended after a diagnosis of UTI? and (5) How should children be followed after a UTI has been diagnosed? I will follow that same sequence in this commentary. I will mention some important areas of agreement and make other suggestions when I believe alternative recommendations are supported by available evidence. Unlike the 1999 practice parameter, which recommended urine testing for all children aged 2 months to 2 years with unexplained fever,2 the new guideline recommends selective urine testing based on the prior probability of UTI, which is an important improvement. The guideline and technical report do an admirable job summarizing the main factors that determine that prior probability (summarized in Table 1 in the clinical report). This table will help clinicians estimate whether the probability of UTI is ≥1% or ≥2%, values that the authors suggest are reasonable thresholds for urine testing. The guideline appropriately states that the threshold probability for urine testing is not known and that “clinicians will choose a threshold depending on factors such as their confidence that contact will be maintained through the illness… … Address correspondence to Thomas B. Newman, MD, MPH, Department of Epidemiology and Biostatistics, UCSF Box 0560, San Francisco, CA 94143. E-mail: newman{at}epi.ucsf.edu