The UTICalc calculating tool demonstrated strong clinical utility in detecting urinary tract infections (UTIs) in preverbal, pre-toilet-trained children, a multicenter prospective cohort study found.

However, in the studied cohort of over 2500 febrile children aged 2-24 months presenting from 2022 to 2025 at two tertiary-care pediatric emergency departments, UTICalc did not outperform clinicians’ assessments. 

The study suggests the tool’s overall accuracy and net benefit are positive. “These findings support the use of UTICalc to guide UTI evaluation and management in young children,” wrote first author Ceilidh Kinlin, MD, a pediatric emergency medicine specialist at the Children’s Hospital of Eastern Ontario in Ottawa, Canada, and colleagues in JAMA Network Open. 

Diagnosing UTI in preverbal and pre-toilet-trained children is notoriously challenging because of nonspecific symptoms and difficulty obtaining clean urine samples. In older children, reporting of urinary symptoms such as dysuria and frequency generally guides testing decisions.

“Young children often cannot describe symptoms, and many illnesses cause fever without clear signs pointing to the source,” Kinlin said. “In addition, collecting a urine sample in children who are not yet toilet-trained can be difficult.” Clinicians must therefore balance risks such as missing a UTI that needs treatment and performing unnecessary urine testing or prescribing antibiotics when the likelihood of infection is low, she added.

“For example, a healthy-appearing 8-month-old with fever but no obvious source of infection is a common scenario in the emergency department or primary care setting, and clinicians may differ in whether they decide to obtain a urine sample.”

Study Details

Among 2561 participants — 47% female children, 64% under 12 months — 111 children, or 4%, were classified as having a UTI. In the full sample, 88.1% had urine testing and/or provided follow-up data.

The clinical model AUROC (area under the receiver operating characteristic curve) measured the model’s ability to distinguish between two classes across different thresholds as 84.1% (95% CI, 80.4%-87.9%). At a 2% UTI risk threshold, sensitivity was 96.4% and specificity was 34.1%, whereas at a 5% risk threshold, sensitivity was 82.0% and specificity 73.8%.

The clinical-plus-dipstick model AUROC was 95.3% (95% CI, 93.3%-97.4%), with 94.0% sensitivity and 86.9% specificity at 5% risk. For clinicians, the sensitivity and specificity were 98.2% and 57.3%, respectively. Both models were associated with positive net benefit across a range of risk thresholds.

The tool estimates the probability of UTI based on clinical scoring features — age, sex, fever characteristics, and circumcision status — to help guide the decision to perform urine testing. It does not replace diagnostic testing, Kinlin stressed. “If the calculated risk is above a chosen threshold, the next step is still to obtain a urine sample for urinalysis and culture to confirm the diagnosis.”

If the estimated risk is very low, unnecessary urine testing may be avoided, which can require catheterization in young children, she said.

The calculator also takes into account the possibility of co-infection. The presence of another infection source lowers the estimated risk for UTI. “However, like any clinical tool, it cannot account for every possible situation or combination of illnesses,” Kinlin said.

UTICalc does not distinguish between different types of infections or further refine the risk for UTI based on the specific alternative diagnosis, added Tamar R. Lubell, MD, a pediatric emergency medicine specialist and an assistant professor of pediatrics at Columbia University Vagelos College of Physicians and Surgeons, in New York City, and not a participant in the study. “So clinical judgment remains important when more than one potential source of fever is present.”

Lubell noted that at a 2% UTI risk threshold for testing, clinician judgement led to less overall testing than that recommended by UTICalc — and without missing more UTIs. “That likely reflects the high level of expertise of the clinicians in the pediatric emergency department settings in which the study was conducted,” she told Medscape Medical News.

“This finding suggests that UTICalc may provide the greatest value and help streamline decision-making in settings with less pediatric-specific expertise or with anticipated barriers to follow-up, where a more standardized, conservative approach to urine testing may be warranted.”

In the meantime, Kinlin’s advises primary care physicians and community pediatricians to rely on clinical judgment when deciding on a urine test, especially in straightforward cases. “In trickier situations, UTICalc can serve as a helpful guide.” Future research should assess UTICalc’s performance across varying levels of clinician suspicion before testing and evaluate earlier integration into emergency department workflows.

The authors listed no specific funding for this research.

Coauthor Zemek reported receiving institutional grants from multiple non-private-sector research funding bodies, including the Canadian Institutes of Health Research, the Ontario Ministry of Health, the Public Health Agency of Canada, and Health Canada. He reported having a founding partner and a shareholder in 360 Concussion Care, a learning system and concussion clinics network. Coauthor Bhatt reported receiving institutional grants from CHEO Research Institute during the study. Lubell had no conflicts of interest.