地域医療と健康教育

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Clinical Training of Primary Health Care Physicians to Reduce False Positive Diagnoses of Pediatric Urinary Tract Infections

Urrutia-Herrera D, Greiner F, Tejada-Tayabas LM, Monárrez-Espino J

Background: Presumptive clinical diagnosis of pediatric urinary tract infections (UTI) remains in practice in many low- and middle-income countries in spite of its limited accuracy; improving its precision could be potentially useful until more accurate methods can be implemented in resource-limited locations.
Objective: To assess whether clinical training can result in a reduction of false positive diagnoses of pediatric UTIs.
Methods: A non-randomized pragmatic trial was conducted in six medical units. Each arm included doctors from two units. Those in the first (IG9, n=14) and second (IG20, n=14) group received 9 h and 20 h training, respectively; the control group (CG, n=17) received none. Training in the IG9 consisted of three sessions lasting 3 h each, one per week over three consecutive weeks, and for the IG20 training spread over five weeks with two 2 h sessions per week. Sessions were led by an expert pediatrician covering relevant UTI topics; focus was given on common signs and symptoms including fever of unknown origin, urinary urgency, hematuria, dysuria, fetid urine, and suprapubic pain. A total of 134 children between two months and nine years were diagnosed; 41, 44, and 49 from the CG, IG9 and IG20, respectively. The main measure of effect was the difference in the proportions of accurate positive clinical diagnoses between the trained groups and the control using urine culture as standard. Adjusted odds ratios (OR) from binary logistic regression were computed to estimate the probability of correctly diagnosing a UTI adjusting by physicians’ sex, age, years of experience, postgraduate education, and  re-training knowledge.
Results: The proportion of accurate diagnoses was 39.0, 27.3 and 32.7% in the CG, IG9 and IG20, respectively. Doctors trained for 9 or 20 h had a non-significantly lower chance of a correct diagnosis (OR; 95% CI for IG9=0.57;0.21-1.5, IG20=0.55; 0.21-1.4).
Conclusion: Training did not reduce false positives diagnoses. Confirmatory methods are required to diagnose UTIs in children with symptomatology.