Role of urine Gram stain in young febrile infants with a suspected urinary tract infection: a cohort study.

Abstract

To analyse the performance of the urine Gram stain for predicting a positive urine culture (UC) in young infants with fever without source (FWS) and pyuria. Observational study; secondary analysis of a prospective registry-based cohort study. Paediatric emergency department; tertiary teaching hospital. Infants ≤90 days old with FWS, pyuria and urine Gram stain requested seen between 2010 and 2022. Performance of the Gram stain, defined as positive if any bacteria were seen, for predicting urinary tract infection (UTI: UC by urethral catheterisation growing >10 000 CFU/mL of a single bacterial pathogen). Among 367 febrile infants with pyuria, 281 (76.6%) had a positive Gram stain and 306 (83.3%) had a positive UC (277; 90.5% <i>Escherichia coli</i>).Rates of positive UC in patients with positive and negative Gram stains were 97.2% and 38.4%, respectively (p<0.01), showing a sensitivity of 89.2% (95% CI: 85.2% to 92.2%) and a specificity of 86.9% (95% CI: 76.2% to 93.2%). Sensitivity was lower for diagnosing UTIs caused by bacteria other than <i>E. coli</i> (69.0% vs 91.3% for UTIs caused by <i>E. coli</i>; p<0.01).Two (2.1%) of the 86 infants with negative Gram stains were diagnosed with bacteraemia unrelated to a UTI (<i>Streptococcus pneumoniae</i> and <i>Staphylococcus aureus</i>). Around a third of infants with pyuria and a negative Gram stain will eventually be diagnosed with a UTI. These patients have a higher rate of UTIs caused by bacteria other than <i>E. coli</i>. Bacterial infections other than UTIs should also be considered in such cases.