Race and Urinary Tract Infections in Young Children With Fever

In 2011, the American Academy of Pediatrics (AAP) published an evidence-based clinical practice guideline on “The Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months” (hereafter referred to as the AAP UTI Guideline).¹ Based on 2 studies,^2,3 Key Action Statement 2 of the AAP UTI Guideline recommended the use of the following risk factors to assess the pretest likelihood of UTI: age, temperature, sex, circumcision status, presence of another source of fever, and race.¹ Shaikh et al⁴ developed an online application (UTICalc) that obviated the need for clinicians to remember the various risk factors; the application made it easy to apply the risk factors (including race) and determine a precise pretest probability of UTI. Within the past several years, however, awareness about structural racism has increased in society in general and in medicine as well,⁵ including the adverse effects on child and adolescent health.⁶ Race is recognized as a social construct, rather than a biological one, and there is concern about the reporting of race in medical and science journals,⁷ particularly in clinical algorithms.⁸ Currently, at the request of Congress, the Agency for Healthcare Research and Quality is conducting a comprehensive review of the potential for the use of race in medical algorithms to result in bias in health care.⁹ The US Preventive Services Task Force is also engaged in activities to mitigate systemic racism in clinical preventive services.^10,11 In January 2020, Kowalsky et al¹² focused concern about the use of race in assessing the likelihood of UTI in young children children with fever in their Viewpoint article “The Case for Removing Race From the American Academy of Pediatrics Clinical Practice Guideline for Urinary Tract Infection in Infants and Young Children With Fever.” The AAP embraced the concerns expressed in the Viewpoint and, in May 2021, retired the UTI Guideline.¹³