In a recent cohort study published in JAMA Network Open, researchers from the United States of America (US) investigated the population incidence of urinary tract infections (UTIs) among children. Further, they examined the potential changes in incidence and disease severity associated with the coronavirus disease 2019 (COVID-19) pandemic. They found that UTI diagnosis was reduced during the early pandemic with no change in disease severity, indicating a role for reduced over- or misdiagnosis.
Study: Incidence of Pediatric Urinary Tract Infections Before and During the COVID-19 Pandemic. Image Credit: Chamaiporn Naprom / Shutterstock
Background
UTIs are highly prevalent bacterial infections in children, particularly in infants, constituting a significant health concern that may lead to hospitalization, imaging, and even surgical intervention. Although UTIs are commonly treated with antibiotics, their population incidence and optimal diagnostic criteria remain understudied.
The reduced use of health care during the COVID-19 pandemic provides a unique opportunity to examine UTI testing, treatment, and outcomes. While various studies explored the shifts in medical care patterns and common diagnoses during the pandemic, there is a gap in investigating the incidence of pediatric UTI diagnoses in various healthcare settings. Therefore, researchers in the present study aimed to estimate the population-level UTI incidence and evaluate changes in UTI diagnosis, along with associated measures of severity, including intensive care unit (ICU) admissions and hospitalizations, during the COVID-19 pandemic.
About the study
This retrospective observational cohort study was conducted from 2016 to 2021 using the US commercial claims database MarketScan. It includes data on 13,221,117 privately insured individuals under 18 years, of which 49% were females. The participants were grouped into four classes based on age in years– 0 to 1, 2 to 5, 6 to 11, and 12 to 17. Additionally, a cohort of infants aged up to 60 days was examined a priori.
The study duration was classified into a pre-pandemic (January 2016 to February 2020) and pandemic period (April 2020 to December 2021). The pandemic period was further classified as early pandemic (April 2020 to June 2020) and mid-pandemic (July 2020 to December 2021). The study’s primary outcome was the incidence of UTIs in inpatient or ambulatory settings. Owing to controversial diagnostic criteria and lack of availability of test results in coverage claims, a specific UTI diagnosis code (based on relevant International Classification of Diseases 10 codes) and antibiotic treatment were used for defining UTI diagnosis. Any UTI diagnosis within a two-week period following a previous diagnosis was considered a singular event.
Statistical analysis included the use of Poisson 95% confidence intervals, an interrupted time-series model, regression, and two-sided hypothesis tests. UTI severity was primarily measured via hospitalization for ages 0–17 years and via ICU admissions for the cohort aged <60 days. Secondary measures of UTI severity were dehydration, sepsis, shock, acute kidney injury, and duration of stay ≥4 days.
Results and discussion
For the entire age range (0 to 17 years), the average UTI incidence was found to be 1.300 UTIs per 100 patient years. The UTI incidence per 100 patient-years was estimated to be 0.87, 0.86, 1.58, 1.24, and 1.37 in the age groups <60 days, 0–1 year, 2–5 years, 6–11 years, and 12–17 years, respectively. Notably, UTI incidence per 100 patient-years was significantly higher in females (2.48) vs. males (0.18). Additionally, UTIs were found to be more common in uncircumcised male infants as compared to circumcised ones.
For the full pediatric cohort, there was an 11.4% annual reduction in UTI diagnoses during the pre-pandemic period, and during the early pandemic, UTI diagnoses decreased by 33.1%. Despite this, hospitalizations with UTI decreased by 17.7% in the early pandemic. Sepsis, shock, and length of stay were also found to decrease during the early pandemic, while no significant difference was observed in dehydration and acute kidney injury.
After an initial decline in UTI diagnoses and severity measures during the first three months of the COVID-19 pandemic, rates returned to near pre-pandemic levels in the full pediatric cohort. For infants aged ≥ 60 days, there was a marked decrease in UTI incidence and diagnoses. However, ICU hospitalizations for this subgroup did not show a statistically significant change.
While the exact mechanism for decreased UTI incidence during the early pandemic is unknown, a decrease in misdiagnosis and overdiagnosis may be a potential explanation. The study is limited by the sole use of commercial claims data, potential miscoding in diagnosis codes, lack of detailed clinical information, and the inability to assess the long-term consequences of sub-optimally treated UTIs.
Conclusion
In conclusion, the present study reports a reduction in UTI diagnoses in the early pandemic period without a statistically significant increase in UTI severity. This updated understanding of UTI epidemiology in children provides important insights for clinical care, resource prioritization, policy-making, and antimicrobial stewardship while guiding future research.