An analysis of private insurance claims data shows there was a dramatic decline in one of the most common bacterial infections in children during the early months of the COVID-19 pandemic.
The study, published today in JAMA Network Open, found that urinary tract infection (UTI) diagnoses in children fell by 33% during the first 3 months of the pandemic, without associated changes in disease severity. The authors of the study say that while several pandemic-related factors could have played a role, the findings may provide insight into the diagnosis and management of UTIs in children.
"Fewer UTI diagnoses during the pandemic in the face of unchanged severe outcomes may suggest that overdiagnosis and/or overtreatment were previously occurring," they wrote.
Sharp decline in first 3 pandemic months
To assess the population incidence of UTIs in children and pandemic-related changes in UTI diagnoses and severity, a team led by researchers at Stanford University School of Medicine examined US commercial claims data for children ages 0 to 17 from 2016 through 2021. They compared the prepandemic period (January 1, 2016, to February 29, 2020) with the early pandemic (April 1 to June 30, 2020) and midpandemic (July 1, 2020 to December 31, 2021) periods.
The primary outcome was the incidence of UTI, defined as having a UTI diagnostic code with an accompanying antibiotic prescription. Measurements of UTI severity included hospitalizations, intensive care unit admissions, shock, sepsis, and length of stay (LOS) in the hospital.
Fewer UTI diagnoses during the pandemic in the face of unchanged severe outcomes may suggest that overdiagnosis and/or overtreatment were previously occurring.
Among the more than 13.2 million children (51% male) included in the analysis, the mean UTI incidence was 1.30 (95% confidence interval [CI], 1.296 to 1.304) per 100 patient-years. Incidence was substantially higher in girls than boys (2.48 vs 0.18), highest in children ages 2 to 5 years (1.58), and lowest in children 1 year old and younger (0.86).
While UTI diagnoses were declining by roughly 11% each year during the prepandemic period, UTI incidence fell 33.1% (95% CI, –39.4% to –26.1%) compared with the prepandemic trends. In addition, hospitalizations with UTI declined 17.7% (95% CI, –31.1% to –1.1%), as did shock (–57.4%), sepsis (–50.8%), and LOS (–34.4%). In a subgroup of infants aged 60 days or younger, UTI incidence and hospitalizations fell 52.1% and 73.4%, respectively.
After the first 3 months of the pandemic, however, UTI incidence nearly returned to prepandemic levels for all children (–4.3%), and prepandemic seasonal patterns of peaks in the fall and winter also returned.
Pandemic-related factors
The study authors say it's unclear exactly how the pandemic and associated lockdowns in the early months may have affected UTI incidence, since UTIs aren't known to be a transmissible infection and wouldn't have been affected by physical distancing measures. One possible explanation is that the substantial decline in non-COVID healthcare visits during the early pandemic may have led to fewer children with mild UTIs seeking care and a subsequent decrease in urine testing for UTIs.
But they also suggest the observed decline in non-COVID respiratory infections early in the pandemic may be related to the drop in UTI diagnoses.
"The decrease in viral respiratory infections during the pandemic may have subsequently led to fewer evaluations for fever or other vague symptoms possibly attributable to UTI, which would decrease the potential for an incorrect diagnosis, or misdiagnosis, of UTI," they wrote.
The authors note that the downward trend they observed in UTI incidence during the prepandemic period is an important finding that warrants further analysis. That trend, they say, could be explained by stricter criteria for UTI diagnosis, along with diagnostic and antimicrobial stewardship efforts.
"This updated characterization of UTI epidemiologic factors in children may help inform clinical care, prioritization of resources and other policy discussions, quality improvement and stewardship efforts, and future research," they wrote.
