Comparative Evaluation of Dipstick Tests and Urine Microscopy Against Culture in Childhood Urinary Tract Infection: A Prospective Study

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While urine culture remains the gold standard, rapid screening tests are essential for timely management. Methods A prospective study was conducted in 178 children aged 3 months to 12 years clinically suspected of UTI. All participants underwent urine dipstick testing for leukocyte esterase (LE) and nitrites, urine microscopy, and culture. Sensitivity, specificity, predictive values, likelihood ratios, and receiver operating characteristic (ROC) curves were calculated. Results Urine culture was positive in 17.4% of cases, most commonly isolating Escherichia coli and Acinetobacter baumannii . LE showed sensitivity of 80.6% and specificity of 61.2%, while nitrite demonstrated excellent specificity (94.6%) and moderate sensitivity (74.2%). Microscopy yielded the highest sensitivity (93.5%) and negative predictive value (98.3%). Combined LE and nitrite positivity increased specificity (97.9%) and positive predictive value (86.3%) but reduced sensitivity (61.2%). ROC analysis showed the highest AUC for nitrite (0.829), followed by microscopy (0.799) and LE (0.787). Conclusion Urine microscopy is the most sensitive screening modality, while nitrite provides excellent rule-in value. Combined dipstick testing enhances specificity, supporting its integration into diagnostic algorithms alongside culture. Pediatric urinary tract infection Urinedipstick Leukocyteesterase Nitritetest Urine microscopy Figures Figure 1 Introduction Urinary tract infections (UTIs) represent one of the most frequent bacterial infections in the pediatric age group and constitute a major source of morbidity worldwide. In children, UTIs are clinically important because they can present as acute illnesses with fever and systemic features, may recur over time, and can also lead to long-term complications such as renal scarring, secondary hypertension, and, in severe cases, progression to chronic kidney disease if they are not promptly identified and treated. These potential consequences emphasize the importance of early recognition and accurate diagnosis of UTI in childhood [ 1 , 2 ]. Epidemiological data suggest that UTIs are encountered throughout childhood, although the prevalence and risk vary with age and sex. The estimated lifetime risk of developing a UTI before the age of 14 years is around 1–3% in boys and 3–10% in girls, with the risk highest in the first few years of life [ 3 ]. In infancy, boys—particularly uncircumcised boys—are at greater risk; however, beyond the first year of life, girls predominate with a male-to-female ratio of approximately 1:10 [ 4 ]. Febrile neonates have been reported to have an incidence of UTI as high as 20% in uncircumcised boys and around 5% in girls, reflecting both host factors and local defense mechanisms [ 4 , 5 ]. After the neonatal period, there is a bimodal peak of incidence: during the first year of life and again during the toilet-training period between two and four years of age [ 5 ]. The risk of UTI is strongly influenced by several host and environmental factors. Female sex, structural anomalies of the urinary tract such as vesicoureteric reflux (VUR) and obstructive uropathy, bladder–bowel dysfunction, and constipation all predispose to infection [ 6 ]. In addition, iatrogenic factors, such as prolonged urinary catheterization, increase susceptibility [ 7 ]. Children with immunodeficiencies or those on long-term immunosuppressive therapy are also at greater risk. From a microbiological perspective, the majority of pediatric UTIs are caused by uropathogenic Escherichia coli (UPEC), which accounts for 70–90% of cases globally. Other organisms such as Klebsiella pneumoniae, Enterococcus faecalis, Proteus mirabilis, Pseudomonas aeruginosa, and, in some cases, fungal pathogens such as Candida species, are also implicated [ 6 , 7 ]. These pathogens often possess virulence factors including adhesins, fimbriae, and toxins that facilitate colonization of the urinary tract. Ascending infection from the periurethral region is the most common pathophysiological mechanism. The clinical presentation of UTI in children is notoriously variable and often nonspecific, which complicates diagnosis. Infants and neonates may present with fever, irritability, poor feeding, vomiting, jaundice, or poor weight gain, all of which overlap with many other pediatric conditions [ 8 ]. Older children, in contrast, are more likely to report localizing urinary symptoms such as dysuria, frequency, urgency, suprapubic pain, flank discomfort, or hematuria [ 9 ]. The presence of systemic features such as high-grade fever and flank pain usually indicates upper tract involvement or pyelonephritis. Given these nonspecific and age-dependent presentations, laboratory evaluation is crucial. The diagnostic gold standard remains urine culture, which demonstrates the growth of a single organism in significant numbers (≥ 10⁵ CFU/mL). However, urine culture has practical limitations: it requires 24–48 hours to yield results, is vulnerable to contamination during specimen collection, and may be influenced by prior antibiotic use [ 10 ]. These challenges often delay initiation of targeted therapy, making rapid diagnostic tests highly relevant in clinical practice. Urine dipstick testing and urine microscopy are the most widely available and commonly used rapid tests. The dipstick method detects surrogate markers of infection: leukocyte esterase (LE), which reflects the presence of neutrophils in urine, and nitrite, which is formed when nitrate-reducing bacteria metabolize dietary nitrates [ 11 ]. LE has high sensitivity but limited specificity because pyuria may occur in other inflammatory conditions. Nitrite, conversely, has high specificity but low sensitivity, particularly in infants who void frequently and in infections caused by non–nitrate-reducing organisms [ 12 ]. The diagnostic performance of these tests improves when LE and nitrite are interpreted together, although reported sensitivities and specificities vary widely between studies. Microscopy of urine is another cornerstone test that allows direct visualization of pyuria, bacteriuria, red cells, and casts. It is generally more sensitive than dipstick testing, but it requires trained personnel and laboratory resources that may not be consistently available in low-resource settings [ 13 ].Although dipstick and microscopy are extensively used, their diagnostic accuracy compared with culture varies across age groups, sample collection methods, and geographical settings. This variation creates uncertainty for clinicians when making rapid treatment decisions. In resource-limited settings, where culture facilities may not be universally accessible, the performance of these rapid screening tools becomes even more critical. The present study was therefore undertaken to evaluate the diagnostic accuracy of urine dipstick (LE and nitrite) and microscopy against urine culture in children clinically suspected of UTI. By analyzing sensitivity, specificity, predictive values, likelihood ratios, and receiver operating characteristic (ROC) curves, we aimed to clarify the relative strengths of these rapid diagnostic methods and provide evidence-based recommendations for their use in pediatric practice.. Materials and Methods Study Design and Setting This was a prospective observational study conducted in the Department of Pediatrics of a tertiary care teaching hospital over a period of twelve months. The objective was to assess the diagnostic accuracy of urine dipstick and microscopy against urine culture in children suspected to have UTI. Participants Inclusion criteria All children aged between 3 months and 12 years presenting with clinical suspicion of UTI were eligible. Clinical suspicion was defined by the presence of the following age-appropriate features: Infants and young children : fever without focus, vomiting, abdominal pain, or failure to thrive. Older children : dysuria, urinary urgency, increased frequency, suprapubic pain, or flank pain. Exclusion criteria Children were excluded if they had received antibiotics prior to enrollment, were younger than 3 months or older than 12 years, had congenital or acquired immunodeficiency, had prior urinary catheterization, were on long-term steroids or other immunosuppressants, or if parents/guardians did not provide informed consent. Clinical Evaluation Each participant underwent detailed history-taking and comprehensive physical examination. General examination included assessment of vital signs (pulse, respiratory rate, blood pressure, temperature), pallor, cyanosis, jaundice, lymphadenopathy, and edema. Systemic examination covered abdominal, respiratory, cardiovascular, and neurological systems. Random blood sugar was also recorded. Laboratory and Radiological Investigations Baseline laboratory investigations performed included complete blood count (hemoglobin, total and differential leukocyte counts), renal function tests (serum urea, creatinine), liver function tests (SGOT, SGPT, bilirubin), and random blood sugar. Imaging with ultrasonography (USG) of the abdomen was conducted in all participants to detect any structural abnormalities. A micturatingcystourethrogram (MCU) was performed in selected children based on clinical indications such as recurrent UTI or abnormal USG findings. Urine Sample Collection Urine was collected under aseptic conditions using age-appropriate methods: Toilet-trained children : clean-catch midstream urine sample after cleansing the perineum with sterile water. Children under 5 years : sterile catheterization using Foley’s catheter. Each child provided three separate urine samples, which were subjected to microscopy, dipstick analysis, and culture. Urine Microscopy A fresh sample was centrifuged at 1500 rpm for 5 minutes, and the sediment was examined under high power. Pyuria was defined as > 5 white blood cells (WBCs) per high power field (hpf) in centrifuged urine or > 10 WBCs/mm³ in uncentrifuged urine. Bacteriuria was recorded when bacteria were visualized. Dipstick Analysis Commercial dipsticks were used to detect leukocyte esterase and nitrite. LE positivity was indicated by a color change corresponding to manufacturer standards. Nitrite positivity was defined as a pink coloration. Both results were interpreted by trained staff. Urine Culture Culture and sensitivity testing was performed using standard microbiological techniques. A colony count of ≥ 10⁵ CFU/mL of a single organism was considered significant bacteriuria. Mixed growths were considered contaminated and repeated if possible. Antimicrobial susceptibility testing was performed as per CLSI guidelines. Treatment Empirical antibiotics were initiated after sample collection, based on institutional protocol. Therapy was later modified according to culture and sensitivity results. Statistical Analysis Data were analyzed using SPSS version 25. Diagnostic parameters including sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), likelihood ratios, and 95% confidence intervals were calculated for dipstick and microscopy, with urine culture as the gold standard. ROC curves were generated to evaluate overall diagnostic performance. Ethical Considerations The study protocol was approved by the Institutional Ethics Committee,GMCAurangabad,ref(letter no:Pharm/IEC-GMCA/70/2020 Dated-12/11/2020). Informed consent Written informed consent was obtained from parents or legal guardians before enrollment. Results A total of 178 children clinically suspected of urinary tract infection (UTI) were included in the study. The mean age of participants was 5.2 years, with nearly half (47.8%) being school-going children aged 5–12 years. Infants (3 months–1 year), toddlers (1–3 years), and preschoolers (3–5 years) comprised 10.7%, 23.0%, and 18.5% of the cohort, respectively. Females constituted a slightly higher proportion (54.5%) compared to males (45.5%). Among male participants, two-thirds (68.0%) were uncircumcised, while 32.0% were circumcised. Most children belonged to rural backgrounds (60.1%), whereas 39.9% resided in urban areas. Socioeconomic stratification using the Modified Kuppuswamy Scale (2019) revealed that the majority were from class III (57.9%), followed by class IV (25.3%), class II (13.5%), and class V (3.4%); none belonged to class I. The detailed baseline demographic characteristics of study participants are presented in Table 1 . Table 1. Baseline demographic characteristics of study participants (N = 178) Characteristic Category Frequency Percentage (%) Age group 3 months – 1 year 19 10.7 1 – 3 years 41 23.0 3 – 5 years 33 18.5 5 – 12 years 85 47.8 Gender Male 81 45.5 Female 97 54.5 Male subgroup Uncircumcised 55 68.0* Circumcised 26 32.0* Residence Rural 107 60.1 Urban 71 39.9 Socioeconomic class (MKS) Class I 0 0.0 Class II 24 13.5 Class III 103 57.9 Class IV 45 25.3 Class V 6 3.4 Table 2.Clinical features of patients Clinical feature Frequency Percentage (%) Fever 165 92.7 Abdominal pain 65 36.5 Dysuria 53 29.8 Vomiting 47 26.4 Decreased urine output 20 11.2 Increased frequency 9 5.1 Constipation 10 5.6 Past history of UTI 6 3.4 Fever was the predominant presenting symptom, observed in 165 children (92.7%). Abdominal pain was reported in 65 children (36.5%), while dysuria was documented in 53 cases (29.8%). Vomiting occurred in 47 participants (26.4%), whereas less common symptoms included decreased urine output in 20 children (11.2%), constipation in 10 (5.6%), and increased urinary frequency in 9 (5.1%). A past history of urinary tract infection was reported in 6 children (3.4%). The distribution of clinical features is summarized in Table 2. Table 3. Urine Culture Findings Urine culture result Frequency Percentage (%) Sterile 147 82.6 Positive cultures 31 17.4 — E. coli 8 4.5 — Acinetobacter baumannii 8 4.5 — Klebsiella pneumoniae 5 2.8 — Enterococcus 4 2.2 — Candida species 2 1.1 — Proteus 2 1.1 — Pseudomonas 2 1.1 Of the 178 children evaluated, urine culture was sterile in 147 cases (82.6%) and yielded positive growth in 31 cases (17.4%). Among culture-positive isolates, Escherichia coli and Acinetobacter baumannii were the most frequently detected organisms, each accounting for 8 cases (4.5%). Klebsiella pneumoniae was isolated in 5 children (2.8%), while Enterococcus was identified in 4 (2.2%). Less common isolates included Candida species, Proteus species, and Pseudomonas species, each recovered in 2 cases (1.1%). The detailed distribution of culture results is presented in Table 3. Table 4. Summary of Diagnostic Performance Test Sensitivity Specificity PPV NPV LR+ LR– Leukocyte esterase 80.6% 61.2% 30.5% 93.8% 1.9 0.31 Nitrite 74.2% 94.6% 74.2% 94.6% 20.4 0.21 Leukocyte esterase + nitrite 61.2% 97.9% 86.3% 92.3% 29 0.39 Urine microscopy 93.5% 80.9% 50.9% 98.3% 12.6 0.15 When evaluated individually, leukocyte esterase (LE) demonstrated a sensitivity of 80.6% and a negative predictive value (NPV) of 93.8%, but its specificity was modest at 61.2%, resulting in a relatively low positive predictive value (PPV) of 30.5%. Nitrite testing showed excellent specificity (94.6%) and high NPV (94.6%), with sensitivity of 74.2% and a PPV of 74.2%.When LE and nitrite were used in combination, specificity rose to 97.9% and PPV to 86.3%, although sensitivity decreased to 61.2%. This combination also produced the highest positive likelihood ratio (LR+) of 29, suggesting strong diagnostic utility for ruling in infection.Urine microscopy demonstrated the best overall sensitivity (93.5%) and the highest NPV (98.3%), indicating strong ability to rule out UTI. Its specificity was 80.9%, with a PPV of 50.9%, and likelihood ratios of +12.6 and –0.15. A detailed summary of diagnostic performance is presented in Table 4 Discussion In this prospective study, 178 children aged 3 months to 12 years with suspected urinary tract infection (UTI) were evaluated. Urine culture was positive in 17.4% of cases, with Escherichia coli and Acinetobacter baumannii being the most frequently isolated organisms. Fever was the most common presenting symptom (92.7%), followed by abdominal pain (36.5%) and dysuria (29.8%). These findings are consistent with previous reports highlighting fever as the predominant presentation of pediatric UTI, with younger children often exhibiting nonspecific signs such as irritability or poor feeding [11–13]. Among diagnostic modalities, urine microscopy demonstrated the highest sensitivity (93.5%) and negative predictive value (98.3%), indicating strong rule-out capability. This aligns with prior studies emphasizing that microscopy, when performed carefully, is a reliable rapid screening tool for pediatric UTI [11,14]. Nitrite dipstick showed excellent specificity (94.6%) and positive predictive value (74.2%), reflecting its utility in detecting nitrate-reducing gram-negative bacteria, predominantly E. coli [11,12,15]. Leukocyte esterase (LE) showed moderate sensitivity (80.6%) but lower specificity (61.2%), suggesting that while it is useful for initial screening, LE alone is insufficient to confirm infection [11,12,16]. Combined LE and nitrite testing increased specificity to 97.9% and positive predictive value to 86.3%, although sensitivity declined to 61.2%, consistent with meta-analyses indicating that dual-positive dipstick tests improve rule-in accuracy but may reduce sensitivity (Whiting et al., 2005; Williams et al., 2010) [17,18]. ROC analysis revealed the highest area under the curve (AUC) for nitrite (0.829), followed by microscopy (0.799) and LE (0.787) [11,14,19,20]. Leukocyte esterase in our cohort had a sensitivity of 80.6%, comparable to other regional studies (Gorelick et al., 1999; Huicho et al., 2002) [14,15]. The slightly lower sensitivity compared to reports such as Bafna et al. may reflect differences in population characteristics, prevalence, and urine collection methods [16]. LE specificity in our study (61.2%) was lower than in some previous cohorts (e.g., Al Musawi et al.), suggesting higher false positives due to contamination or transient pyuria, but similar to real-world studies using clean-catch samples (Williams et al., 2010) [14,17]. These observations reinforce that LE is a sensitive screening marker but insufficient alone for definitive diagnosis. Nitrite testing showed excellent specificity (94.6%), consistent with its role in detecting bacteriuria from nitrate-reducing gram-negative organisms [11,17,18]. Sensitivity was 74.2%, higher than older studies, likely due to careful sample handling and a larger proportion of infections caused by nitrate-reducing pathogens in our cohort [18,19]. Biological limitations, including frequent voiding in infants and infections with non–nitrate-reducing bacteria, reduce sensitivity, making nitrite most reliable as a rule-in test but inadequate for ruling out infection [18,19]. Urine microscopy demonstrated superior sensitivity (93.5%), consistent with its ability to accurately detect pyuria and bacteriuria [11,14,15]. The high negative predictive value (98.3%) indicates that negative microscopy effectively excludes UTI in this population. Variations in microscopy performance across studies likely relate to differences in centrifugation, operator expertise, and prevalence of infection (Devillé et al., 2004; Mori et al., 2007) [14,20]. Likelihood ratio analysis contextualizes clinical relevance: our combined LE + nitrite positive likelihood ratio (+LR) of 29 indicates that children with a positive combined dipstick are 29 times more likely to have culture-confirmed infection than those with negative results, aligning with prior meta-analyses (Whiting et al., 2005; Mori et al., 2010) [21,22]. The negative likelihood ratio (–LR) for the combined dipstick (0.39) and microscopy (0.15) indicates that microscopy is superior for ruling out disease, whereas combined dipstick testing is particularly powerful for ruling in UTI [21,22]. ROC analysis further supports these findings: nitrite AUC 0.829, microscopy 0.799, and LE 0.787 demonstrate good discrimination and reflect previous systematic reviews on the diagnostic accuracy of pediatric dipstick and microscopy (Dadzie et al., 2019; Kocer et al., 2017; Marques et al., 2017) [23–25]. Our findings indicate that urine microscopy is the most sensitive screening modality and provides excellent negative predictive value, making it ideal for ruling out UTI. Nitrite dipstick offers high specificity and reliably rules in infection, while LE improves overall sensitivity but shows variable specificity. In resource-limited settings, combined dipstick testing can guide early management and empirical therapy while awaiting culture results. Clinicians should consider patient age and method of urine collection when interpreting results to minimize false positives and negatives. Strengths and Limitations The strengths of this study include its prospective design, standardized diagnostic definitions, and comprehensive evaluation of dipstick, microscopy, and culture in the same cohort. The inclusion of likelihood ratios and ROC curves adds practical interpretability beyond simple sensitivity and specificity. Limitations include its single-center design and relatively low culture positivity (17.4%), which may affect predictive values. In addition, long-term follow-up for renal outcomes was not performed. Finally, variations in bladder incubation time were not systematically measured, which may influence nitrite sensitivity. Conclusion In summary, urine microscopy offers the strongest rule-out capacity, nitrite dipstick serves as the best rule-in test, and combined LE + nitrite achieves excellent specificity and PPV. Integrating these rapid tools into pediatric practice, while confirming with culture, can optimize management, reduce unnecessary antibiotic use, and improve outcomes for children with suspected UTI. Declarations Funding Declaration: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. References Shaikh N, Morone NE, Bost JE, Farrell MH. Prevalence of urinary tract infection in childhood: a meta-analysis. Pediatr Infect Dis J. 2008;27(4):302–8. Coulthard MG, Lambert HJ, Keir MJ. Occurrence of renal scars in children after their first referral for urinary tract infection. BMJ. 1997;315(7113):918–9. Hellström A, Hanson E, Hansson S, Hjälmås K, Jodal U. Association between urinary symptoms at 7 years old and previous urinary tract infection. Arch Dis Child. 1991;66(2):232–4. Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics. 2011;128(3):595–610. Elder JS. Urinary tract infections. In: Kliegman RM, Geme JW, Blum NJ, Shah SS, Tasker RC, Wilson KM, editors. Nelson Textbook of Pediatrics. 21st ed. Philadelphia: Elsevier; 2020. p. 2766–75. Beetz R. Mild dehydration: a risk factor of urinary tract infection? Eur J Pediatr. 2003;162(9):682–3. Wiswell TE, Hachey WE. Urinary tract infections and the uncircumcised state: an update. ClinPediatr (Phila). 1993;32(3):130–4. Zorc JJ, Levine DA, Platt SL, Dayan PS, Macias CG, Krief W, et al. Clinical and demographic factors associated with urinary tract infection in young febrile infants. Pediatrics. 2005;116(3):644–8. Shaw KN, Gorelick M, McGowan KL, Yakscoe NM, Schwartz JS. Prevalence of urinary tract infection in febrile young children in the emergency department. Pediatrics. 1998;102(2):e16. Karmazyn BK, Alazraki AL, Anupindi SA, Dempsey-Robertson M, Dillman JR, Dorfman SR, et al. ACR Appropriateness Criteria® Urinary Tract Infection—Child. J Am CollRadiol. 2017;14(5S):S362–71. Gorelick MH, Shaw KN. Screening tests for urinary tract infection in children: a meta-analysis. Pediatrics. 1999;104(5):e54. Devillé WL, Yzermans JC, van Duijn NP, Bezemer PD, van der Windt DA, Bouter LM. The urine dipstick test useful to rule out infections. A meta-analysis of the accuracy. BMC Urol. 2004;4:4. Williams GJ, Macaskill P, Chan SF, Turner RM, Hodson E, Craig JC. Absolute and relative accuracy of rapid urine tests for urinary tract infection in children: a meta-analysis. Lancet Infect Dis. 2010;10(4):240–50. Huicho L, Campos-Sanchez M, Alamo C, Ortiz J, Rivera J. Accuracy of urine analysis tests for diagnosing urinary tract infection in children: a systematic review. ActaPaediatr. 2002;91(9):935–41. Williams G, Craig JC. Long-term antibiotics for preventing recurrent urinary tract infection in children. Cochrane Database Syst Rev. 2019;4(4):CD001534. Bafna V, Jha P, Yadav S, Yadav R, Mishra B, Mishra J. Comparative evaluation of dipstick, microscopy and culture in urinary tract infection diagnosis. Int J ContempPediatr. 2019;6(6):2398–403. Al Musawi M, Yousif T, Al Ansari A, Abdulla M, Khadim M. Accuracy of urinalysis and urine microscopy in predicting urinary tract infection. Bahrain Med Bull. 2016;38(2):97–100. Ojha AR, Sharma S, Shrestha P, Poudel P, Bhandari R, Shrestha B. Diagnostic accuracy of urine dipstick and microscopy in children with urinary tract infection. Kathmandu Univ Med J (KUMJ). 2019;17(67):220–4. Fernandes ET, Malek RS, Burke EC. Diagnostic value of urinalysis in urinary tract infection. South Med J. 1992;85(6):633–6. Goldsmith BM, Campos JM. Urinary tract infections in children: how reliable is the nitrite test? ClinPediatr (Phila). 1990;29(3):214–8. Whiting P, Westwood M, Watt I, Cooper J, Kleijnen J. Rapid tests and urine sampling techniques for the diagnosis of urinary tract infection in children under five years: a systematic review. BMC Pediatr. 2005;5:4. Mori R, Lakhanpaul M, Verrier-Jones K. Diagnosis and management of urinary tract infection in children: summary of NICE guidance. BMJ. 2007;335(7616):395–7. Mori R, Yonemoto N, Fitzgerald A, Tullus K, Verrier-Jones K, Lakhanpaul M. Diagnostic performance of urine dipstick testing in children with suspected UTI: a systematic review of relationship with age and comparison with microscopy. ActaPaediatr. 2010;99(4):581–4. Dadzie I, Appiah-Korang L, Boaitey YA, Twumasi P, Nguah SB. Diagnostic accuracy of dipstick urinalysis in predicting urinary tract infection among under-five children in Ghana. BMC Pediatr. 2019;19:124. Marques F, Leal I, Trindade H, Rocha R, Carvalho F, Gomes C, et al. Diagnostic accuracy of dipstick urinalysis in children with suspected urinary tract infection. Eur J Pediatr. 2017;176(11):1539–44. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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1","display":"","copyAsset":false,"role":"figure","size":396667,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u0026nbsp;\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7832534/v1/a0d0439c4bc412e8879dd54e.png"},{"id":94987585,"identity":"05558744-9253-4984-80be-22ad6e393054","added_by":"auto","created_at":"2025-11-03 07:02:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1107452,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7832534/v1/fab3abd4-9b67-4d78-b390-0575f413bc7b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparative Evaluation of Dipstick Tests and Urine Microscopy Against Culture in Childhood Urinary Tract Infection: A Prospective Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eUrinary tract infections (UTIs) represent one of the most frequent bacterial infections in the pediatric age group and constitute a major source of morbidity worldwide. In children, UTIs are clinically important because they can present as acute illnesses with fever and systemic features, may recur over time, and can also lead to long-term complications such as renal scarring, secondary hypertension, and, in severe cases, progression to chronic kidney disease if they are not promptly identified and treated. These potential consequences emphasize the importance of early recognition and accurate diagnosis of UTI in childhood [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eEpidemiological data suggest that UTIs are encountered throughout childhood, although the prevalence and risk vary with age and sex. The estimated lifetime risk of developing a UTI before the age of 14 years is around 1\u0026ndash;3% in boys and 3\u0026ndash;10% in girls, with the risk highest in the first few years of life [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In infancy, boys\u0026mdash;particularly uncircumcised boys\u0026mdash;are at greater risk; however, beyond the first year of life, girls predominate with a male-to-female ratio of approximately 1:10 [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Febrile neonates have been reported to have an incidence of UTI as high as 20% in uncircumcised boys and around 5% in girls, reflecting both host factors and local defense mechanisms [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. After the neonatal period, there is a bimodal peak of incidence: during the first year of life and again during the toilet-training period between two and four years of age [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe risk of UTI is strongly influenced by several host and environmental factors. Female sex, structural anomalies of the urinary tract such as vesicoureteric reflux (VUR) and obstructive uropathy, bladder\u0026ndash;bowel dysfunction, and constipation all predispose to infection [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In addition, iatrogenic factors, such as prolonged urinary catheterization, increase susceptibility [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Children with immunodeficiencies or those on long-term immunosuppressive therapy are also at greater risk.\u003c/p\u003e\u003cp\u003eFrom a microbiological perspective, the majority of pediatric UTIs are caused by uropathogenic Escherichia coli (UPEC), which accounts for 70\u0026ndash;90% of cases globally. Other organisms such as Klebsiella pneumoniae, Enterococcus faecalis, Proteus mirabilis, Pseudomonas aeruginosa, and, in some cases, fungal pathogens such as Candida species, are also implicated [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. These pathogens often possess virulence factors including adhesins, fimbriae, and toxins that facilitate colonization of the urinary tract. Ascending infection from the periurethral region is the most common pathophysiological mechanism.\u003c/p\u003e\u003cp\u003eThe clinical presentation of UTI in children is notoriously variable and often nonspecific, which complicates diagnosis. Infants and neonates may present with fever, irritability, poor feeding, vomiting, jaundice, or poor weight gain, all of which overlap with many other pediatric conditions [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Older children, in contrast, are more likely to report localizing urinary symptoms such as dysuria, frequency, urgency, suprapubic pain, flank discomfort, or hematuria [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The presence of systemic features such as high-grade fever and flank pain usually indicates upper tract involvement or pyelonephritis.\u003c/p\u003e\u003cp\u003eGiven these nonspecific and age-dependent presentations, laboratory evaluation is crucial. The diagnostic gold standard remains urine culture, which demonstrates the growth of a single organism in significant numbers (\u0026ge;\u0026thinsp;10⁵ CFU/mL). However, urine culture has practical limitations: it requires 24\u0026ndash;48 hours to yield results, is vulnerable to contamination during specimen collection, and may be influenced by prior antibiotic use [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. These challenges often delay initiation of targeted therapy, making rapid diagnostic tests highly relevant in clinical practice.\u003c/p\u003e\u003cp\u003eUrine dipstick testing and urine microscopy are the most widely available and commonly used rapid tests. The dipstick method detects surrogate markers of infection: leukocyte esterase (LE), which reflects the presence of neutrophils in urine, and nitrite, which is formed when nitrate-reducing bacteria metabolize dietary nitrates [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. LE has high sensitivity but limited specificity because pyuria may occur in other inflammatory conditions. Nitrite, conversely, has high specificity but low sensitivity, particularly in infants who void frequently and in infections caused by non\u0026ndash;nitrate-reducing organisms [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The diagnostic performance of these tests improves when LE and nitrite are interpreted together, although reported sensitivities and specificities vary widely between studies.\u003c/p\u003e\u003cp\u003eMicroscopy of urine is another cornerstone test that allows direct visualization of pyuria, bacteriuria, red cells, and casts. It is generally more sensitive than dipstick testing, but it requires trained personnel and laboratory resources that may not be consistently available in low-resource settings [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].Although dipstick and microscopy are extensively used, their diagnostic accuracy compared with culture varies across age groups, sample collection methods, and geographical settings. This variation creates uncertainty for clinicians when making rapid treatment decisions. In resource-limited settings, where culture facilities may not be universally accessible, the performance of these rapid screening tools becomes even more critical.\u003c/p\u003e\u003cp\u003eThe present study was therefore undertaken to evaluate the diagnostic accuracy of urine dipstick (LE and nitrite) and microscopy against urine culture in children clinically suspected of UTI. By analyzing sensitivity, specificity, predictive values, likelihood ratios, and receiver operating characteristic (ROC) curves, we aimed to clarify the relative strengths of these rapid diagnostic methods and provide evidence-based recommendations for their use in pediatric practice..\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design and Setting\u003c/h2\u003e\u003cp\u003eThis was a prospective observational study conducted in the Department of Pediatrics of a tertiary care teaching hospital over a period of twelve months. The objective was to assess the diagnostic accuracy of urine dipstick and microscopy against urine culture in children suspected to have UTI.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eInclusion criteria\u003c/h2\u003e\u003cp\u003eAll children aged between 3 months and 12 years presenting with clinical suspicion of UTI were eligible. Clinical suspicion was defined by the presence of the following age-appropriate features:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eInfants and young children\u003c/b\u003e: fever without focus, vomiting, abdominal pain, or failure to thrive.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eOlder children\u003c/b\u003e: dysuria, urinary urgency, increased frequency, suprapubic pain, or flank pain.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eExclusion criteria\u003c/h3\u003e\n\u003cp\u003eChildren were excluded if they had received antibiotics prior to enrollment, were younger than 3 months or older than 12 years, had congenital or acquired immunodeficiency, had prior urinary catheterization, were on long-term steroids or other immunosuppressants, or if parents/guardians did not provide informed consent.\u003c/p\u003e\n\u003ch3\u003eClinical Evaluation\u003c/h3\u003e\n\u003cp\u003eEach participant underwent detailed history-taking and comprehensive physical examination. General examination included assessment of vital signs (pulse, respiratory rate, blood pressure, temperature), pallor, cyanosis, jaundice, lymphadenopathy, and edema. Systemic examination covered abdominal, respiratory, cardiovascular, and neurological systems. Random blood sugar was also recorded.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eLaboratory and Radiological Investigations\u003c/h2\u003e\u003cp\u003eBaseline laboratory investigations performed included complete blood count (hemoglobin, total and differential leukocyte counts), renal function tests (serum urea, creatinine), liver function tests (SGOT, SGPT, bilirubin), and random blood sugar. Imaging with ultrasonography (USG) of the abdomen was conducted in all participants to detect any structural abnormalities. A micturatingcystourethrogram (MCU) was performed in selected children based on clinical indications such as recurrent UTI or abnormal USG findings.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eUrine Sample Collection\u003c/h3\u003e\n\u003cp\u003eUrine was collected under aseptic conditions using age-appropriate methods:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eToilet-trained children\u003c/b\u003e: clean-catch midstream urine sample after cleansing the perineum with sterile water.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eChildren under 5 years\u003c/b\u003e: sterile catheterization using Foley\u0026rsquo;s catheter.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eEach child provided three separate urine samples, which were subjected to microscopy, dipstick analysis, and culture.\u003c/p\u003e\n\u003ch3\u003eUrine Microscopy\u003c/h3\u003e\n\u003cp\u003eA fresh sample was centrifuged at 1500 rpm for 5 minutes, and the sediment was examined under high power. Pyuria was defined as \u0026gt;\u0026thinsp;5 white blood cells (WBCs) per high power field (hpf) in centrifuged urine or \u0026gt;\u0026thinsp;10 WBCs/mm\u0026sup3; in uncentrifuged urine. Bacteriuria was recorded when bacteria were visualized.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eDipstick Analysis\u003c/h2\u003e\u003cp\u003eCommercial dipsticks were used to detect leukocyte esterase and nitrite. LE positivity was indicated by a color change corresponding to manufacturer standards. Nitrite positivity was defined as a pink coloration. Both results were interpreted by trained staff.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eUrine Culture\u003c/h2\u003e\u003cp\u003eCulture and sensitivity testing was performed using standard microbiological techniques. A colony count of \u0026ge;\u0026thinsp;10⁵ CFU/mL of a single organism was considered significant bacteriuria. Mixed growths were considered contaminated and repeated if possible. Antimicrobial susceptibility testing was performed as per CLSI guidelines.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eTreatment\u003c/h2\u003e\u003cp\u003eEmpirical antibiotics were initiated after sample collection, based on institutional protocol. Therapy was later modified according to culture and sensitivity results.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eData were analyzed using SPSS version 25. Diagnostic parameters including sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), likelihood ratios, and 95% confidence intervals were calculated for dipstick and microscopy, with urine culture as the gold standard. ROC curves were generated to evaluate overall diagnostic performance.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eEthical Considerations\u003c/h2\u003e\u003cp\u003e The study protocol was approved by the Institutional Ethics Committee,GMCAurangabad,ref(letter no:Pharm/IEC-GMCA/70/2020 Dated-12/11/2020).\u003c/p\u003e\u003c/div\u003e\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from parents or legal guardians before enrollment.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 178 children clinically suspected of urinary tract infection (UTI) were included in the study. The mean age of participants was 5.2 years, with nearly half (47.8%) being school-going children aged 5\u0026ndash;12 years. Infants (3 months\u0026ndash;1 year), toddlers (1\u0026ndash;3 years), and preschoolers (3\u0026ndash;5 years) comprised 10.7%, 23.0%, and 18.5% of the cohort, respectively. Females constituted a slightly higher proportion (54.5%) compared to males (45.5%). Among male participants, two-thirds (68.0%) were uncircumcised, while 32.0% were circumcised.\u003c/p\u003e\n\u003cp\u003eMost children belonged to rural backgrounds (60.1%), whereas 39.9% resided in urban areas. Socioeconomic stratification using the Modified Kuppuswamy Scale (2019) revealed that the majority were from class III (57.9%), followed by class IV (25.3%), class II (13.5%), and class V (3.4%); none belonged to class I. The detailed baseline demographic characteristics of study participants are presented in \u003cstrong\u003eTable 1\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eTable 1. Baseline demographic characteristics of study participants (N = 178)\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3 months \u0026ndash; 1 year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e1 \u0026ndash; 3 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e3 \u0026ndash; 5 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e5 \u0026ndash; 12 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e47.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e45.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e54.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003eMale subgroup\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eUncircumcised\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e68.0*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCircumcised\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e32.0*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eResidence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e107\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e60.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e39.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003eSocioeconomic class (MKS)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eClass I\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eClass II\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eClass III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e103\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e57.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eClass IV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eClass V\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2.Clinical features of patients\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eClinical feature\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eFever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e165\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e92.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAbdominal pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e36.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDysuria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e29.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eVomiting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e26.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDecreased urine output\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eIncreased frequency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eConstipation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePast history of UTI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eFever was the predominant presenting symptom, observed in 165 children (92.7%). Abdominal pain was reported in 65 children (36.5%), while dysuria was documented in 53 cases (29.8%). Vomiting occurred in 47 participants (26.4%), whereas less common symptoms included decreased urine output in 20 children (11.2%), constipation in 10 (5.6%), and increased urinary frequency in 9 (5.1%). A past history of urinary tract infection was reported in 6 children (3.4%). The distribution of clinical features is summarized in Table 2.\u003c/p\u003e\n\u003ch2\u003eTable 3. Urine Culture Findings\u003c/h2\u003e\n\u003ctable border=\"1\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eUrine culture result\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSterile\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e147\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e82.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePositive cultures\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e31\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e17.4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026mdash; E. coli\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026mdash; Acinetobacter baumannii\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026mdash; Klebsiella pneumoniae\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026mdash; Enterococcus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026mdash; Candida species\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026mdash; Proteus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026mdash; Pseudomonas\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eOf the 178 children evaluated, urine culture was sterile in 147 cases (82.6%) and yielded positive growth in 31 cases (17.4%). Among culture-positive isolates, Escherichia coli and Acinetobacter baumannii were the most frequently detected organisms, each accounting for 8 cases (4.5%). Klebsiella pneumoniae was isolated in 5 children (2.8%), while Enterococcus was identified in 4 (2.2%). Less common isolates included Candida species, Proteus species, and Pseudomonas species, each recovered in 2 cases (1.1%). The detailed distribution of culture results is presented in Table 3.\u003c/p\u003e\n\u003cp\u003eTable 4. Summary of Diagnostic Performance\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTest\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eSensitivity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eSpecificity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePPV\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eNPV\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLR+\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLR\u0026ndash;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLeukocyte esterase\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e80.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e61.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e93.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNitrite\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e74.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e94.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e74.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e94.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLeukocyte esterase + nitrite\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e61.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e97.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e86.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e92.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eUrine microscopy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e93.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e80.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e50.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e98.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eWhen evaluated individually, leukocyte esterase (LE) demonstrated a sensitivity of 80.6% and a negative predictive value (NPV) of 93.8%, but its specificity was modest at 61.2%, resulting in a relatively low positive predictive value (PPV) of 30.5%. Nitrite testing showed excellent specificity (94.6%) and high NPV (94.6%), with sensitivity of 74.2% and a PPV of 74.2%.When LE and nitrite were used in combination, specificity rose to 97.9% and PPV to 86.3%, although sensitivity decreased to 61.2%. This combination also produced the highest positive likelihood ratio (LR+) of 29, suggesting strong diagnostic utility for ruling in infection.Urine microscopy demonstrated the best overall sensitivity (93.5%) and the highest NPV (98.3%), indicating strong ability to rule out UTI. Its specificity was 80.9%, with a PPV of 50.9%, and likelihood ratios of +12.6 and \u0026ndash;0.15. A detailed summary of diagnostic performance is presented in \u003cstrong\u003eTable 4\u003c/strong\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this prospective study, 178 children aged 3 months to 12 years with suspected urinary tract infection (UTI) were evaluated. Urine culture was positive in 17.4% of cases, with \u003cem\u003eEscherichia coli\u003c/em\u003e and \u003cem\u003eAcinetobacter baumannii\u003c/em\u003e being the most frequently isolated organisms. Fever was the most common presenting symptom (92.7%), followed by abdominal pain (36.5%) and dysuria (29.8%). These findings are consistent with previous reports highlighting fever as the predominant presentation of pediatric UTI, with younger children often exhibiting nonspecific signs such as irritability or poor feeding [11\u0026ndash;13].\u003c/p\u003e\n\u003cp\u003eAmong diagnostic modalities, urine microscopy demonstrated the highest sensitivity (93.5%) and negative predictive value (98.3%), indicating strong rule-out capability. This aligns with prior studies emphasizing that microscopy, when performed carefully, is a reliable rapid screening tool for pediatric UTI [11,14]. Nitrite dipstick showed excellent specificity (94.6%) and positive predictive value (74.2%), reflecting its utility in detecting nitrate-reducing gram-negative bacteria, predominantly \u003cem\u003eE. coli\u003c/em\u003e [11,12,15]. Leukocyte esterase (LE) showed moderate sensitivity (80.6%) but lower specificity (61.2%), suggesting that while it is useful for initial screening, LE alone is insufficient to confirm infection [11,12,16]. Combined LE and nitrite testing increased specificity to 97.9% and positive predictive value to 86.3%, although sensitivity declined to 61.2%, consistent with meta-analyses indicating that dual-positive dipstick tests improve rule-in accuracy but may reduce sensitivity (Whiting et al., 2005; Williams et al., 2010) [17,18]. ROC analysis revealed the highest area under the curve (AUC) for nitrite (0.829), followed by microscopy (0.799) and LE (0.787) [11,14,19,20].\u003c/p\u003e\n\u003cp\u003eLeukocyte esterase in our cohort had a sensitivity of 80.6%, comparable to other regional studies (Gorelick et al., 1999; Huicho et al., 2002) [14,15]. The slightly lower sensitivity compared to reports such as Bafna et al. may reflect differences in population characteristics, prevalence, and urine collection methods [16]. LE specificity in our study (61.2%) was lower than in some previous cohorts (e.g., Al Musawi et al.), suggesting higher false positives due to contamination or transient pyuria, but similar to real-world studies using clean-catch samples (Williams et al., 2010) [14,17]. These observations reinforce that LE is a sensitive screening marker but insufficient alone for definitive diagnosis.\u003c/p\u003e\n\u003cp\u003eNitrite testing showed excellent specificity (94.6%), consistent with its role in detecting bacteriuria from nitrate-reducing gram-negative organisms [11,17,18]. Sensitivity was 74.2%, higher than older studies, likely due to careful sample handling and a larger proportion of infections caused by nitrate-reducing pathogens in our cohort [18,19]. Biological limitations, including frequent voiding in infants and infections with non\u0026ndash;nitrate-reducing bacteria, reduce sensitivity, making nitrite most reliable as a rule-in test but inadequate for ruling out infection [18,19].\u003c/p\u003e\n\u003cp\u003eUrine microscopy demonstrated superior sensitivity (93.5%), consistent with its ability to accurately detect pyuria and bacteriuria [11,14,15]. The high negative predictive value (98.3%) indicates that negative microscopy effectively excludes UTI in this population. Variations in microscopy performance across studies likely relate to differences in centrifugation, operator expertise, and prevalence of infection (Devill\u0026eacute; et al., 2004; Mori et al., 2007) [14,20].\u003c/p\u003e\n\u003cp\u003eLikelihood ratio analysis contextualizes clinical relevance: our combined LE + nitrite positive likelihood ratio (+LR) of 29 indicates that children with a positive combined dipstick are 29 times more likely to have culture-confirmed infection than those with negative results, aligning with prior meta-analyses (Whiting et al., 2005; Mori et al., 2010) [21,22]. The negative likelihood ratio (\u0026ndash;LR) for the combined dipstick (0.39) and microscopy (0.15) indicates that microscopy is superior for ruling out disease, whereas combined dipstick testing is particularly powerful for ruling in UTI [21,22]. ROC analysis further supports these findings: nitrite AUC 0.829, microscopy 0.799, and LE 0.787 demonstrate good discrimination and reflect previous systematic reviews on the diagnostic accuracy of pediatric dipstick and microscopy (Dadzie et al., 2019; Kocer et al., 2017; Marques et al., 2017) [23\u0026ndash;25].\u003c/p\u003e\n\u003cp\u003eOur findings indicate that urine microscopy is the most sensitive screening modality and provides excellent negative predictive value, making it ideal for ruling out UTI. Nitrite dipstick offers high specificity and reliably rules in infection, while LE improves overall sensitivity but shows variable specificity. In resource-limited settings, combined dipstick testing can guide early management and empirical therapy while awaiting culture results. Clinicians should consider patient age and method of urine collection when interpreting results to minimize false positives and negatives.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths and Limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe strengths of this study include its prospective design, standardized diagnostic definitions, and comprehensive evaluation of dipstick, microscopy, and culture in the same cohort. The inclusion of likelihood ratios and ROC curves adds practical interpretability beyond simple sensitivity and specificity.\u003c/p\u003e\n\u003cp\u003eLimitations include its single-center design and relatively low culture positivity (17.4%), which may affect predictive values. In addition, long-term follow-up for renal outcomes was not performed. Finally, variations in bladder incubation time were not systematically measured, which may influence nitrite sensitivity.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn summary, urine microscopy offers the strongest rule-out capacity, nitrite dipstick serves as the best rule-in test, and combined LE + nitrite achieves excellent specificity and PPV. Integrating these rapid tools into pediatric practice, while confirming with culture, can optimize management, reduce unnecessary antibiotic use, and improve outcomes for children with suspected UTI.\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding Declaration:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eShaikh N, Morone NE, Bost JE, Farrell MH. Prevalence of urinary tract infection in childhood: a meta-analysis. Pediatr Infect Dis J. 2008;27(4):302\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eCoulthard MG, Lambert HJ, Keir MJ. Occurrence of renal scars in children after their first referral for urinary tract infection. BMJ. 1997;315(7113):918\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eHellstr\u0026ouml;m A, Hanson E, Hansson S, Hj\u0026auml;lm\u0026aring;s K, Jodal U. Association between urinary symptoms at 7 years old and previous urinary tract infection. Arch Dis Child. 1991;66(2):232\u0026ndash;4.\u003c/li\u003e\n\u003cli\u003eSubcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics. 2011;128(3):595\u0026ndash;610.\u003c/li\u003e\n\u003cli\u003eElder JS. Urinary tract infections. In: Kliegman RM, Geme JW, Blum NJ, Shah SS, Tasker RC, Wilson KM, editors. Nelson Textbook of Pediatrics. 21st ed. Philadelphia: Elsevier; 2020. p. 2766\u0026ndash;75.\u003c/li\u003e\n\u003cli\u003eBeetz R. Mild dehydration: a risk factor of urinary tract infection? Eur J Pediatr. 2003;162(9):682\u0026ndash;3.\u003c/li\u003e\n\u003cli\u003eWiswell TE, Hachey WE. Urinary tract infections and the uncircumcised state: an update. ClinPediatr (Phila). 1993;32(3):130\u0026ndash;4.\u003c/li\u003e\n\u003cli\u003eZorc JJ, Levine DA, Platt SL, Dayan PS, Macias CG, Krief W, et al. Clinical and demographic factors associated with urinary tract infection in young febrile infants. Pediatrics. 2005;116(3):644\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eShaw KN, Gorelick M, McGowan KL, Yakscoe NM, Schwartz JS. Prevalence of urinary tract infection in febrile young children in the emergency department. Pediatrics. 1998;102(2):e16.\u003c/li\u003e\n\u003cli\u003eKarmazyn BK, Alazraki AL, Anupindi SA, Dempsey-Robertson M, Dillman JR, Dorfman SR, et al. ACR Appropriateness Criteria\u0026reg; Urinary Tract Infection\u0026mdash;Child. J Am CollRadiol. 2017;14(5S):S362\u0026ndash;71.\u003c/li\u003e\n\u003cli\u003eGorelick MH, Shaw KN. Screening tests for urinary tract infection in children: a meta-analysis. Pediatrics. 1999;104(5):e54.\u003c/li\u003e\n\u003cli\u003eDevill\u0026eacute; WL, Yzermans JC, van Duijn NP, Bezemer PD, van der Windt DA, Bouter LM. The urine dipstick test useful to rule out infections. A meta-analysis of the accuracy. BMC Urol. 2004;4:4.\u003c/li\u003e\n\u003cli\u003eWilliams GJ, Macaskill P, Chan SF, Turner RM, Hodson E, Craig JC. Absolute and relative accuracy of rapid urine tests for urinary tract infection in children: a meta-analysis. Lancet Infect Dis. 2010;10(4):240\u0026ndash;50.\u003c/li\u003e\n\u003cli\u003eHuicho L, Campos-Sanchez M, Alamo C, Ortiz J, Rivera J. Accuracy of urine analysis tests for diagnosing urinary tract infection in children: a systematic review. ActaPaediatr. 2002;91(9):935\u0026ndash;41.\u003c/li\u003e\n\u003cli\u003eWilliams G, Craig JC. Long-term antibiotics for preventing recurrent urinary tract infection in children. Cochrane Database Syst Rev. 2019;4(4):CD001534.\u003c/li\u003e\n\u003cli\u003eBafna V, Jha P, Yadav S, Yadav R, Mishra B, Mishra J. Comparative evaluation of dipstick, microscopy and culture in urinary tract infection diagnosis. Int J ContempPediatr. 2019;6(6):2398\u0026ndash;403.\u003c/li\u003e\n\u003cli\u003eAl Musawi M, Yousif T, Al Ansari A, Abdulla M, Khadim M. Accuracy of urinalysis and urine microscopy in predicting urinary tract infection. Bahrain Med Bull. 2016;38(2):97\u0026ndash;100.\u003c/li\u003e\n\u003cli\u003eOjha AR, Sharma S, Shrestha P, Poudel P, Bhandari R, Shrestha B. Diagnostic accuracy of urine dipstick and microscopy in children with urinary tract infection. Kathmandu Univ Med J (KUMJ). 2019;17(67):220\u0026ndash;4.\u003c/li\u003e\n\u003cli\u003eFernandes ET, Malek RS, Burke EC. Diagnostic value of urinalysis in urinary tract infection. South Med J. 1992;85(6):633\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eGoldsmith BM, Campos JM. Urinary tract infections in children: how reliable is the nitrite test? ClinPediatr (Phila). 1990;29(3):214\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eWhiting P, Westwood M, Watt I, Cooper J, Kleijnen J. Rapid tests and urine sampling techniques for the diagnosis of urinary tract infection in children under five years: a systematic review. BMC Pediatr. 2005;5:4.\u003c/li\u003e\n\u003cli\u003eMori R, Lakhanpaul M, Verrier-Jones K. Diagnosis and management of urinary tract infection in children: summary of NICE guidance. BMJ. 2007;335(7616):395\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eMori R, Yonemoto N, Fitzgerald A, Tullus K, Verrier-Jones K, Lakhanpaul M. Diagnostic performance of urine dipstick testing in children with suspected UTI: a systematic review of relationship with age and comparison with microscopy. ActaPaediatr. 2010;99(4):581\u0026ndash;4.\u003c/li\u003e\n\u003cli\u003eDadzie I, Appiah-Korang L, Boaitey YA, Twumasi P, Nguah SB. Diagnostic accuracy of dipstick urinalysis in predicting urinary tract infection among under-five children in Ghana. BMC Pediatr. 2019;19:124.\u003c/li\u003e\n\u003cli\u003eMarques F, Leal I, Trindade H, Rocha R, Carvalho F, Gomes C, et al. Diagnostic accuracy of dipstick urinalysis in children with suspected urinary tract infection. Eur J Pediatr. 2017;176(11):1539\u0026ndash;44.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Pediatric urinary tract infection, Urinedipstick, Leukocyteesterase, Nitritetest, Urine microscopy","lastPublishedDoi":"10.21203/rs.3.rs-7832534/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7832534/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eUrinary tract infections (UTIs) are among the most frequent bacterial infections in children and carry a risk of renal scarring, hypertension, and chronic kidney disease if not promptly diagnosed. While urine culture remains the gold standard, rapid screening tests are essential for timely management.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA prospective study was conducted in 178 children aged 3 months to 12 years clinically suspected of UTI. All participants underwent urine dipstick testing for leukocyte esterase (LE) and nitrites, urine microscopy, and culture. Sensitivity, specificity, predictive values, likelihood ratios, and receiver operating characteristic (ROC) curves were calculated.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eUrine culture was positive in 17.4% of cases, most commonly isolating \u003cem\u003eEscherichia coli\u003c/em\u003e and \u003cem\u003eAcinetobacter baumannii\u003c/em\u003e. LE showed sensitivity of 80.6% and specificity of 61.2%, while nitrite demonstrated excellent specificity (94.6%) and moderate sensitivity (74.2%). Microscopy yielded the highest sensitivity (93.5%) and negative predictive value (98.3%). Combined LE and nitrite positivity increased specificity (97.9%) and positive predictive value (86.3%) but reduced sensitivity (61.2%). ROC analysis showed the highest AUC for nitrite (0.829), followed by microscopy (0.799) and LE (0.787).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eUrine microscopy is the most sensitive screening modality, while nitrite provides excellent rule-in value. Combined dipstick testing enhances specificity, supporting its integration into diagnostic algorithms alongside culture.\u003c/p\u003e","manuscriptTitle":"Comparative Evaluation of Dipstick Tests and Urine Microscopy Against Culture in Childhood Urinary Tract Infection: A Prospective Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-27 14:32:44","doi":"10.21203/rs.3.rs-7832534/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d60ec6b8-9b46-445d-a834-c3e4ca9cd3d6","owner":[],"postedDate":"October 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-01T02:38:27+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-27 14:32:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7832534","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7832534","identity":"rs-7832534","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}