Participant characteristics
From January 2021 to June 2021, 23 GPs participated in the study (Table 1). Five GPs declined to participate before study initiation, owing to time restrictions. There was no dropout of participants after study initiation. The GPs were aged between 25 and 66 years and came from 21 general practices located across Flanders in a rural (n = 10) or city (n = 11) area. About half of the practices (n = 12) consisted of GPs only while nine other practices provided multidisciplinary care. The median duration of the interviews was 38 minutes (range: 25–67 minutes).
Table 1. Participant characteristics
Most GPs thought the SARS-Cov-2 pandemic did not affect UTI diagnosis in children at their practice. Four main themes and eleven subthemes were identified. Each quote is labelled with a unique identifier for the GP.
Theme 1: UTI prevalence assumed to be low
The majority of GPs felt that diagnosing UTI is important, but thought that the probability of UTI causing an acute illness was low in general practice:
‘The probability that a child with fever who goes to the paediatrician’s office has a urinary tract infection is a lot higher than in our practice … simply because they see the special cases.’
(GP2, female, 10 years’ experience, city)
‘A urinary tract infection is for me, uhm … especially something that I always keep in the back of my mind because it is less common than an upper respiratory tract infection.’
(GP14, male, 2 years’ experience, city)
‘It is not so frequent that fever in young children leads to a UTI …’
(GP19, male, 35 years’ experience, city)
Theme 2: Urine collection challenges
Subtheme 2a: Adhesive bags are preferred option
In general, GPs preferred using adhesive bags over clean-catch, catheterisation, or suprapubic aspiration in infants, because the former method is non-invasive and ‘easy-to-use’. Many GPs believed that adhesive bags are more successful than clean-catch in young children. Parents can perform this method themselves at home and try several times:
‘If it fails, we can try again … the child will not suffer much, so the threshold is very low.’
(GP20, female, 25 years’ experience, rural)
‘I think that is by far the easiest thing to do.’
(GP12, male, 33 years’ experience, city)
Subtheme 2b: Problems in using adhesive bags
Although adhesive bags were often preferred in infants, GPs reported several disadvantages, such as high contamination rate, and the time and effort required for parents to obtain a sample owing to unsuccessful catches (leaking of the bag):
‘It’s difficult, urine leaks out of the bag, the bag comes off … [sighs] and only a few drops of urine remain inside the bag.’
(GP10, female, 5 years’ experience, city)
‘… you have to have good-quality bags, but … you don’t have much choice.’
(GP11, female, 4.5 years’ experience, rural)
Subtheme 2c: Importance of cooperation by parents
GPs indicated that urine is often obtained at home, and they felt that cooperation from the parents is important for obtaining a reliable urine sample. Some GPs were worried that parents have to put in a lot of effort to obtain urine:
‘… it’s not difficult for me, it’s difficult for the parents.’
(GP15, female, 5.5 years’ experience, rural)
‘… when I propose sticking a bag they [parents] say, ‘’Oh no, last time that also failed.”’
(GP18, female, 10.5 years’ experience, city)
‘… the parents must be willing to cooperate of course, everything depends on that.’
(GP19, male, 35 years’ experience, city)
‘You don’t always see a parent who is motivated to come back or drive to the lab …’
(GP6, female, 4 years’ experience, rural)
Subtheme 2d: Urine catheterisation unacceptable in primary care
Urine catheterisation being performed in primary care did not seem feasible or acceptable, because GPs were worried about the traumatic consequences (physical and psychological) for the child and/or parents, time required for catheterisation, and lack of experience:
‘As an adult that’s already embarrassing. But as a child who doesn’t understand what’s happening … they have to force it. They panic … No, it is painful and then it does not work.’
(GP10, female, 5 years’ experience, city)
GPs preferred to refer children for catheterisation to secondary care, only if they are severely ill. Some GPs were worried that catheterisation is performed too often in secondary care:
‘I would never want to do it in my life … I think that’s way too traumatising! I don’t think a lot of family doctors are up for that … I wonder what the benefit is compared to the traumatising effects […] One of my own children had pyelonephritis […] In the hospital urine was obtained through catheterisation in a rather brutal way […] Even if we don’t have that impression, it can be traumatising for children in the long term … there should be an evidence-based flow to collect urine without being immediately very invasive, even in hospitals.’
(GP7, female, 23 years’ experience, city)
Subtheme 2e: Clean-catch method in infants seems unsuccessful
Half of GPs were not familiar with performing clean-catch in infants, for example, direct first-stream catch of a urine sample in a urine container:
‘I have never heard of that.’
(GP11, female, 4.5 years’ experience, rural)
Most GPs who were familiar with this method had not tried it in practice, because they were concerned that clean-catch with or without stimulation techniques might often be unsuccessful, time consuming, complex, and messy for the parents:
‘You can never take ten or five minutes in the hope that the child will urinate during your consultation.’
(GP14, male, 2.5 years’ experience, city)
‘… a little baby … constantly pushing your hand away … so I know that there are stimulation methods, um … whether they are particularly successful … I don’t think so, but that’s my personal opinion.’
(GP12, male, 33 years’ experience, city)
A minority of GPs had tried the Quick-Wee method,12 or other clean-catch techniques with stimulation and found it impractical:
‘It just doesn’t work […] For young children, it sometimes works … only in very young children, below nine months old.’
(GP18, female, 10.5 years’ experience, city)
‘I have never succeeded in doing that … it is not practically feasible, here in the practice at least.’
(GP13, female, 6 years’ experience, city)
Some GPs would be prepared to ask parents to perform the clean-catch method at home:
‘Maybe the parents can do it at home … with extra stimulation that’s something we can try […] Sometimes it doesn’t have to be difficult and simple tricks are also useful.’
(GP22, male, 8 years’ experience, rural)
Subtheme 2f: Improving collection methods might facilitate urine collection
Facilitators for urine collection were an instruction sheet for parents, skill training for GPs, nurses at the practice, adaptation of available collection methods, novel non-invasive collection methods, sticking the bag themselves at the practice, or an algorithm that informs parents whether they should bring a urine sample to the initial consultation. GPs also highlighted the importance of a well-located, spacious, and attractive toilet room:
‘I have been working for about eight years now, but … I have never had a course on how to obtain a urine sample […] What are the tricks? […] That would be very useful.’
(GP22, male, 8 years’ experience, rural)
Theme 3: Diagnostic uncertainty
Subtheme 3a: UTI features and unexplained fever drive urine analysis
All GPs claimed to obtain urine samples in two clinical situations: children with clinical features of UTI such as dysuria, abdominal pain, incontinence, and vaginal itching, or children with fever without source. Fever without source was often defined as a child with high fever, who looked severely ill, and where the clinical examination was reassuring.
Long duration of fever raised suspicion of UTI. Most GPs used a ‘wait-and-see’ strategy and advised the parent to collect a urine sample if the child remained ill after 2–3 days or longer. A minority of GPs requested a urine sample more rapidly on Day 1 when there was no focus for the infection.
Some GPs mentioned that in using this strategy they only detected severe UTI cases, because young children usually present with vague symptoms:
‘I think we only see it in small children if they have fever, so if it’s a trivial infection, we’re just not going to see it … so I think the moment they come in with symptoms and fever, it’s by definition necessary to detect it quickly …’
(GP11, female, 4.5 years’ experience, rural)
‘[sighs] … a bladder infection occurs usually in an older child … in young children, I don’t think we diagnose bladder infections unless they have pyelonephritis […] We don’t take a urine sample from a child without fever under two to three years of age because they don’t complain of pain while urinating.’
(GP2, female, 10 years’ experience, city)
‘Uhm […] Especially in younger children, UTI is an incidental finding when you take a urine sample.’
(GP9, female, 0.5 years’ experience, city)
‘But I have already experienced it: an ear infection that always comes back and then you do a urine test and suddenly it turns out to be positive … you treat the problem and the ear infection also stays away.’
(GP19, male, 35 years’ experience, city)
Subtheme 3b: Unreliable urine dipstick test
GPs felt the urine dipstick test was not reliable enough because many participants had little confidence in test results owing to fast expiration of the tests and non-concordance with laboratory results:
‘I find the dipstick test very unreliable … it expires very quickly, it discolours when exposed to light.’
(GP14, male, 2 years’ experience, city)
‘I found out that if you leave the jar open too long, all the red blood cell tests are positive [sighs]. ’
(GP17, female, 10.5 years’ experience, city)
Another limitation were the semi-quantitative results, which they thought were more difficult to interpret:
‘It often gives me unconvincing results, light discolouration, what do you do with that? That is difficult.’
(GP13, female, 6 years’ experience, city)
Important advantages of the dipstick test were the user-friendliness and short analysis time, which allows early initiation of empirical antibiotic treatment if the dipstick test is positive.
Subtheme 3c: Manual microscopy laborious
Manual urine microscopy was rarely performed at the practice because GPs thought that performing microscopy was complex and time invasive, or that they lacked experience using the microscope and had more confidence in microscopy results from the laboratory:
‘I don’t think that can be part of today’s general practice … you need time and time is missing.’
(GP20, female, 25 years’ experience, rural)
Some GPs used to have a microscope, but did not use it any more:
‘That’s all so laborious [laughs] … I still have a counting chamber somewhere, but I don’t think I’ve used it for twenty years.’
(GP19, male, 35 years’ experience, city)
Subtheme 3d: C-reactive point-of-care test less relevant for cystitis
According to participants, the C-reactive protein (CRP) point-of-care test seemed useful to rule out pyelonephritis, but less so for cystitis. Some GPs felt that the CRP point-of-care test might be only useful for respiratory infections and not for UTIs.
Subtheme 3e: Long turnaround time of urine culture
The majority of GPs always requested urine culture for children as reference standard and especially to adjust empirical antibiotic treatment.
Some GPs only requested urine culture whenever the dipstick was positive. The most important limitations of urine culture were the long turnaround time:
‘In your reasoning you have to take into account: Is it possible to wait that long or not?’
(GP15, female, 5.5 years’ experience, rural)
Another important barrier was the interpretation when there were atypical pathogens, low colony-counts, multiple pathogens, or no urine white blood cells. Many participants believed there was not sufficient practical guidance for such cases:
‘If you find a pathogen, but no inflammation, no pyuria or haematuria … or multiple pathogens, I sometimes don’t know what to do.’
(GP4, male, 2.5 years’ experience, rural)
GPs believed a novel test for UTI should provide fast, easy-to-interpret, and reliable results at low costs.
Theme 4: Empirical treatment on high suspicion of UTI and referral of severe cases
GPs initiated empirical antibiotic treatment before urine culture results when they had high suspicion of UTI, based on a positive dipstick test or presence of UTI features; and also when they believed the clinical picture did not allow awaiting urine culture results, such as high fever, impression of a severe illness, and low understanding of alarming symptoms by the parents:
‘If it [the dipstick test] clearly discolours, for nitrites and high WBC [white blood cell count] … in a child with high fever where it is difficult to wait, then yes, I will start immediately, I will not wait for the culture.’
(GP21, female, 6 years’ experience, rural)
‘… for children that have had UTIs in the past … or the parents don’t really understand it either. Than you will be tempted to start antibiotics that may not be necessary.’
(GP15, female, 5.5 years’ experience, rural)
‘That waiting time is sometimes a problem … and then you start with amoxicillin sooner than normal.’
(GP11, female, 4.5 years’ experience, rural)
GPs referred children to secondary care based on the impression of a severe illness, such as pyelonephritis, long duration of fever, decreased intake or dehydration, gut feeling of ‘something is wrong’, young age (<3 months), and anxious parents; or for atypical presentations: recurrent UTI, atypical pathogens, urinary tract abnormalities, and history of previous pyelonephritis:
‘Very sick children with a positive culture, we’re going to refer rather easily, eh, in the context of pyelonephritis.’
(GP18, female, 10.5 years’ experience, city)
‘That’s a bit of gut feeling, you can’t really put a finger on that … often high fever, that the child falls asleep on the mom’s lap … no longer drinks anything and has no more pee puddles.’
(GP22, male, 8 years’ experience, rural)
‘Concerning urinary tract infections, I’m mainly going to look at what the recurrent character is, or if there are very special pathogens … so then I will refer, but let’s say for 99% of the urinary tract infections I’m not going to refer.’
(GP12, male, 33 years’ experience, city)
