Downs S M
Pediatrics. 1999 Apr;103(4):e54. doi: 10.1542/peds.103.4.e54.
The Urinary Tract Subcommittee of the American Academy of Pediatrics Committee on Quality Improvement has analyzed alternative strategies for the diagnosis and management of urinary tract infection (UTI) in children. The target population is limited to children between 2 months and 2 years of age who are examined because of fever without an obvious cause. Diagnosis and management of UTI in this group are especially challenging for these three reasons: 1) the manifestation of UTI tends to be nonspecific, and cases may be missed easily; 2) clean voided midstream urine specimens rarely can be obtained, leaving only urine collection methods that are invasive (transurethral catheterization or bladder tap) or result in nonspecific test results (bag urine); and 3) a substantial number of infants with UTI also may have structural or functional abnormalities of the urinary tract that put them at risk for ongoing renal damage, hypertension, and end-stage renal disease (ESRD).
To examine alternative management strategies for UTI in infants, a conceptual model of the steps in diagnosis and management of UTI was developed. The model was expanded into a decision tree. Probabilities for branch points in the decision tree were obtained by review of the literature on childhood UTI. Data were extracted on standardized forms. Cost data were obtained by literature review and from hospital billing data. The data were collated into evidence tables. Analysis of the decision tree was used to produce risk tables and incremental cost-effectiveness ratios for alternative strategies.
Based on the results of this analysis and, when necessary, consensus opinion, the Committee developed recommendations for the management of UTI in this population. This document provides the evidence the Subcommittee used in the development of its recommendations.
The Subcommittee agreed that the objective of the practice parameter would be to minimize the risk of chronic renal damage within reasonable economic constraints. Steps involved in achieving these objectives are: 1) identifying UTI; 2) short-term treatment of UTI; and 3) evaluation for urinary tract abnormalities.
美国儿科学会质量改进委员会泌尿道小组委员会分析了儿童尿路感染（UTI）诊断和管理的替代策略。目标人群仅限于因不明原因发热接受检查的2个月至2岁儿童。该组UTI的诊断和管理特别具有挑战性，原因有三：1）UTI的表现往往不具特异性，病例容易漏诊；2）很少能获得清洁中段尿标本，只剩下侵入性的尿液收集方法（经尿道插管或膀胱穿刺）或导致非特异性检测结果的方法（尿袋收集尿液）；3）大量UTI婴儿也可能有泌尿道结构或功能异常，使他们面临持续肾损伤、高血压和终末期肾病（ESRD）的风险。
为研究婴儿UTI的替代管理策略，制定了UTI诊断和管理步骤的概念模型。该模型扩展为决策树。通过回顾儿童UTI的文献获得决策树分支点的概率。数据以标准化表格提取。成本数据通过文献回顾和医院计费数据获得。数据整理成证据表。决策树分析用于生成替代策略的风险表和增量成本效益比。
基于该分析结果，并在必要时达成共识意见，委员会制定了该人群UTI管理的建议。本文提供了小组委员会在制定建议时使用的证据。
小组委员会一致认为，实践参数的目标是在合理的经济限制内将慢性肾损伤的风险降至最低。实现这些目标所涉及的步骤包括：1）识别UTI；2）UTI的短期治疗；3）泌尿道异常评估。
