The effect of urine culture methods on the diagnosis, treatment and follow-up of urinary tract infection in children aged 2-24 months admitted to the pediatric emergency department

Urinary tract infections (UTI) are the most common causes of fever in children up to 24 months of age and are difficult to recognize because their symptoms are non-specific. There is no definitive consensus on the methods of collecting urine samples in these children who are not toilet trained. The aim of our study is to improve the diagnosis of UTI in children aged 2-24 months who are unable to pass mid-stream urine and to evaluate the effects of the training given to pediatric research assistants and to develop a standard approach protocol for the diagnosis of UTI in the emergency department. For this purpose, the demographic, clinical, laboratory, microbiological, and radiological data of 1553 patients who applied between October 2019 and November 2022 (Period 1), 229 patients who applied during the training and protocol development period between December 2022 and May 2023 (Period 2), and 200 patients who applied during the post-training period (Period 3) were examined. The mean age of a total of 1982 patients included in the study [1096 (55.3%) girls and 886 (44.7%) boys] was 10.4±6.1 months. A total of 648 (32.7) patients were diagnosed with UTI by the physician in the emergency department. Of these 648 patients, the diagnosis of UTI was confirmed in 303 (46.8%) according to the study criteria. When urine culture collection methods were compared according to application periods, the frequency of the two-stage method did not change significantly (p=0.207), while a decrease in the frequency of invasive methods in total (p<0.001) and an increase in the frequency of non-invasive methods (p<0.001) were observed. However, no differences were detected in the median lengths of stay in the emergency department between the periods. Notably, the rate of contamination increased post-education compared to pre-education periods (26.9%, 42%, 34.5%; p<0.001 for periods 1, 2, and 3, respectively; Period 1 vs. Period 2, p<0.001; Period 2 vs. Period 3, p=0.123; Period 1 vs. Period 3, p=0.026). There was no statistically significant difference in contamination rates between pre- and post-education periods (p=0.026, as post-hoc pairwise comparisons did not reach the threshold of p<0.017). Multivariate analysis identified male gender (OR: 2.099, 95% CI: 1.650-2.669, p<0.001) and the use of a direct bag specimen collection method (OR: 18.729, 95% CI: 14.020-25.022, p<0.001) as independent risk factors for contamination, irrespective of the period of application. While we achieved some of our educational goals, it became clear that theoretical education and reminders alone for resident physicians were insufficient to reduce contamination rates. Nevertheless, the increased frequency of residents recording risk factors in the system, the rise in the use of two-step and clean-catch methods, and the increase in the non-invasive collection of urine tests are valuable findings indicating that periodic education, even if theoretical, enhanced awareness in the diagnosis and treatment processes of UTIs. Key words: Urinary tract infection, urine culture, contamination, infant.