Clinical significance of pyuria in pediatric diabetic ketoacidosis: evidence against empirical antibiotic use

Introduction
Diabetic ketoacidosis (DKA) can be associated with severe morbidity and mortality in pediatric patients with type 1 diabetes mellitus, such as pyuria. Clinical association of pyuria with urinary tract infections (UTIs) remains unclear. Misinterpretation of sterile pyuria may lead to unnecessary antimicrobial treatment and hospitalization. The aim of the study was to assess pyuria frequency and its clinical relevance by examining clinical, laboratory, and biochemical parameters in pediatric cases with DKA.

Material and methods
The prospective observational study enrolled 150 children with DKA (1–14 years) who were diagnosed based on the International Society for Pediatric and Adolescent Diabetes criteria and admitted to the Children Welfare Teaching Hospital emergency department. Cases were evaluated by clinical history, physical examination, and laboratory parameters (urinalysis, urine culture, random blood sugar, white blood cell count, platelet count, arterial blood gas analysis, bicarbonate level, blood urea, and serum creatinine). Clinical and laboratory parameters were compared between pyuric (63/150) and non-pyuric groups (87/150).

Results
Pyuria was observed in 42% of DKA cases; only 4.7% had culture-confirmed UTIs. Pyuria was significantly associated with older age (p = 0.02), female sex (p < 0.001), lower random blood glucose (p = 0.03), and lower PaO2 (p = 0.009). Degree of dehydration, level of consciousness, serum ketones, and total leukocyte count were insignificant.

Conclusions
Pyuria is common among pediatric patients with DKA but rarely indicates UTIs. Its presence in DKA patients and correlation with various clinical and biochemical parameters may reflect kidney inflammation, urging more clarification. Routine antibiotic therapy based solely on pyuria is not recommended without clinical or microbiological evidence.