Number of urinary white blood cells is a poor identifier of symptomatic urinary tract infection among children with spina bifida evaluated in the emergency department

Authors

Victor Kucherov, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA. Electronic address: victor_kucherov@urmc.rochester.edu.
Teresa Russell, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
Jacob Smith, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
Sally Zimmermann, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
Elena K. Johnston, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
Md Sohel Rana, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
Elaise Hill, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
Christina P. Ho, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
Hans G. Pohl, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
Briony K. Varda, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.

Document Type

Journal Article

Publication Date

11-1-2025

Journal

Journal of pediatric urology

DOI

10.1016/j.jpurol.2025.10.019

Keywords

Emergency department; Pyuria; Spina bifida; Urinary tract infection; Urinary white blood cells

Abstract

BACKGROUND: Patients with spina bifida evaluated for possible urinary tract infection (UTI) often receive antibiotics inappropriately. One possible factor is the diagnostic value placed in a relatively low threshold for "significant" pyuria (typically >10 white blood cells [WBC] per high power field [HPF]), which is relatively common among these patients. Determination of a more optimal WBC/HPF threshold for "significant" pyuria in this population would improve the accuracy of UTI diagnosis for these patients. OBJECTIVE: To identify the association between urinary WBC/HPF and the presence symptomatic bacteriuria among children with spina bifida presenting to the emergency department (ED) and identify an optimal WBC/HPF threshold value for this association. STUDY DESIGN: We retrospectively reviewed the charts of children (age <21 years) with spina bifida who presented to the ED between January 2016 and January 2020. Patients reliant on intermittent catheterization or volitional voiding/permissive incontinence and had both urinalysis and urine culture were included. The primary outcome was symptomatic bacteriuria, defined as having ≥2 urologic symptoms with >100k CFU/mL urine culture, regardless of urinalysis results. The primary exposure was pyuria, defined as >10 WBC/HPF on urinalysis. Sensitivity analysis was performed to identify an optimal threshold value of urinary WBC/HPF to identify symptomatic bacteriuria, defined as one which maximized the area under the classification receiver-operator curve (AUC). RESULTS: A total of 84 patients across 256 ED encounters were included. The median urinary WBC/HPF value was 40 (range 0-3607) with 68 % of patients having >10 WBC/HPF. Symptomatic bacteriuria was identified in 17 % of patients. Pyuria was associated with symptomatic bacteriuria (p = 0.019), however with poor classification AUC (0.578). On sensitivity analysis, the threshold >45 WBC/HPF maximized the classification AUC for symptomatic bacteriuria (AUC = 0.602), however this did not differ significantly from the prior threshold (p = 0.24) and would still be characterized as a poor classifier. This result was similar when patients were stratified by catheterization status. DISCUSSION: Limitations of this study include its retrospective nature and the definition of symptomatic UTI that was utilized, which has not been validated. The study's findings contribute to the body of literature highlighting the poor performance of pyuria with respect to UTI diagnosis in the spina bifida population. CONCLUSIONS: Urinary WBC/HPF at any threshold performed poorly at classifying symptomatic bacteriuria among children with spina bifida presenting to the ED. The importance of pyuria for UTI diagnosis for these patients should be rethought.

APA Citation

Kucherov, Victor; Russell, Teresa; Smith, Jacob; Zimmermann, Sally; Johnston, Elena K.; Rana, Md Sohel; Hill, Elaise; Ho, Christina P.; Pohl, Hans G.; and Varda, Briony K., "Number of urinary white blood cells is a poor identifier of symptomatic urinary tract infection among children with spina bifida evaluated in the emergency department" (2025). GW Authored Works. Paper 8162.
https://hsrc.himmelfarb.gwu.edu/gwhpubs/8162

Department

Urology