Primary care gaps in pediatric urinary tract infection management: Knowledge, attitudes, and reported practices among general practitioners in Muscat, Oman, and potential implications for renal outcomes

Study design and setting

A multi-center, cross-sectional study was conducted across all 30 PHCs in Muscat Governorate, Sultanate of Oman, between July 2022 and February 2023. Muscat is the capital governorate, serving a population of approximately 1.5 million, with PHCs providing first-contact care for pediatric patients.

Participants and sampling

All 251 GPs employed in Muscat PHCs during the study period were invited to participate. Inclusion criteria were: (1) Currently practicing as a GP in a Muscat PHC, (2) providing direct clinical care to pediatric patients, and (3) willing to provide verbal informed consent. There were no exclusion criteria. A census sampling approach was used to maximize representativeness.

Questionnaire development and validation

A 29-item, English-language, self-administered questionnaire was developed by the research team based on: (1) The Royal Hospital (Muscat) pediatric UTI clinical protocol (2019), (2) the UK NICE guideline CG54 (2018 update),^[11] and (3) the Oman National Formulary (2022) recommendations for empirical pediatric UTI therapy. Antibiotic choice items were aligned with first-line agents for uncomplicated lower UTI in children >3 months per these guidelines: Trimethoprim or nitrofurantoin, unless contraindicated or local resistance exceeds 20%.

The instrument comprised three sections:

• Section 1: Sociodemographics and clinical experience (age, sex, years of practice, pediatric training, weekly pediatric caseload).

• Section 2: Knowledge assessment (symptoms/signs by age group, risk factors for kidney complications, sample collection methods, empirical antibiotic selection, referral indications) using multiple-choice questions, Likert scales, and open-ended items.

• Section 3: Attitudes toward UTI diagnosis and management (5-point and 3-point Likert scales, yes/no items).

Validation occurred in three phases:

1. Content validity: Nine specialists (3 pediatric nephrologists, 6 family medicine consultants) rated each item for necessity using a 3-point scale. Content validity ratios (CVR) ranged from 0.78 to 1.00, exceeding the minimum threshold of 0.78 for n = 9 experts (Lawshe, 1975) [Supplementary Table S1].

2. Face validity: The draft questionnaire was reviewed by five GPs not included in the final sample; no ambiguities were reported.

3. Pilot testing: Twenty-five GPs (10% of the target sample) completed the instrument. Internal consistency was excellent (Cronbach’s α = 0.80).

Additional methodological details

Correct responses for knowledge items were determined based on the Royal Hospital Pediatric UTI protocol (2019) and NICE CG54 (2018 update); an answer key is available from the corresponding author. For items allowing multiple responses (e.g., referral indications in Table 1), participants could select all applicable options; percentages reflect the proportion of respondents selecting each option. Likert-scale responses were grouped as follows: “Agree” = responses 4–5 on a 5-point scale; “Disagree” = responses 1–2; “Neutral/No opinion” = response 3. No composite knowledge score was calculated due to heterogeneous item types (multiple-choice, Likert, open-ended); descriptive frequencies are reported per item to preserve interpretability. Open-ended items were thematically reviewed but not quantitatively analyzed, as they were exploratory and yielded limited additional insight beyond the structured items. The full questionnaire is provided as Supplementary File 1 to enhance transparency and reproducibility.

Data collection

Questionnaires were distributed electronically through secure Ministry of Health email lists and in-person during PHC visits. A 2-week reminder protocol was implemented to optimize response rates. Completed questionnaires were anonymized before data entry.

Ethical considerations

Ethical approval was granted by the Medical Research Ethics Committee, Ministry of Health, Sultanate of Oman (Ref: MH/DGHS/DPT/154/2021). Verbal informed consent was obtained from all participants after distribution of a participant information sheet. Anonymity and confidentiality were maintained throughout; participation was voluntary, with no penalty for withdrawal. The study adhered to the Declaration of Helsinki principles.

Data analysis

Data were entered and analyzed using IBM Statistical Package for the Social Sciences Statistics for Windows, Version 25.0 (IBM Corp., Armonk, NY). Descriptive statistics (frequencies, percentages, means ± standard deviation) summarized participant characteristics, knowledge scores, and attitude responses. All knowledge, attitude, and management data reflect participants’ self-reported responses and stated preferences. These may not correspond to observed clinical behavior, prescription records, or audited referral practices. No inferential statistical testing was performed, as this was an exploratory descriptive study. Exploratory subgroup analyses examining associations between GP characteristics (years of experience, pediatric training, weekly pediatric caseload) and key outcomes (recognition of referral criteria, antibiotic selection preferences) were conducted; no statistically significant associations were found (Chi-square tests, p > 0.05). Given the descriptive design and limited power for subgroup inference, these results are not reported to avoid over-interpretation. Missing data were minimal (<5%/item) and handled using list-wise deletion for each analysis.

Reporting guidelines

This study adheres to the Strengthening of the Reporting of Observational Studies in Epidemiology guidelines for cross-sectional studies [Supplementary File 2: STROBE Checklist].

Sociodemographic characteristics

A total of 227 GPs participated out of 251 invited, yielding a response rate of 90.4%. Participants represented all 30 PHCs in Muscat Governorate. The majority were female (88.3%), with a mean age of 36.0 ± 6.9 years. Most were married (85.5%) and had children (76.8%). Regarding clinical experience, 18.5% had <5 years, 42.8% had 5–10 years, and 38.7% had >10 years of practice. Over half (55.3%) had prior pediatric placement during training, and 23.2% had attended both workshops and placements. Most participants (78.3%) managed >10 pediatric cases weekly [Table 2].

Self-reported knowledge of symptoms and signs

Recognition of key UTI symptoms was generally high. In infants <3 months, 99.0% correctly identified unexplained fever ≥38°C as a key indicator. High recognition rates were also noted for vomiting (91.0%), lethargy/irritability (96.8%), and foul-smelling urine (99.6%). In children >3 months, frequency (91.0%), hematuria (96.0%), and failure to thrive (94.2%) were well recognized. However, non-specific symptoms such as poor feeding and abdominal pain were less consistently identified across age groups [Tables 3a and b].

Recognition of risk factors

Participants demonstrated strong agreement on classic risk factors, including previous UTI (95.2%), poor urine flow (92.9%), and antenatal kidney abnormality (90.8%). However, gaps were observed in recognizing factors associated with long-term kidney complications: only 74.9% agreed on constipation, 82.8% on family history of vesico-ureteric reflux, and 73.1% on evidence of spinal lesions [Table 4].

Investigations and management

For toilet-trained children, 94.7% correctly identified clean-catch urine as the optimal sample collection method. However, for non-toilet-trained children, only 11.9% selected catheterization (recommended pragmatic alternative); 72.0% preferred clean-catch, and 16.6% used urine bags, which have low specificity.

Regarding empirical management for a positive dipstick (leukocytes+, nitrites−), 56.7% correctly initiated antibiotics and sent a culture. Antibiotic selection patterns revealed a preference for broad-spectrum agents: Amoxicillin (82.1% reported as frequently used) and co-amoxiclav (58.1%) were most common. First-line agents for uncomplicated UTI, such as Trimethoprim and Nitrofurantoin, were reported as avoided by 61.4% and 59.4% of participants, respectively ([Table 5]; clinical scenario: empirical treatment for uncomplicated lower UTI in toilet-trained child >3 months).

Referral practices

Recognition of standard referral indications varied: recurrent UTI (74.4%), treatment failure (44.9%), and complicated UTI (21.1%). Critically, only 7.5% identified age <3 months as an indication for urgent specialist referral, despite guidelines emphasizing sepsis and kidney injury risk in this cohort ([Table 1]; multiple responses permitted; percentages reflect proportion of 227 GPs selecting each indication).

Attitudes

Regarding attitudes toward management, 66.9% agreed that UTI is difficult to diagnose in children <2–3 years. While 83.0% believed oral antibiotics suffice for most cases, 59.8% incorrectly believed a 3-day antibiotic course suffices for lower UTI.^[19,20] Conversely, 64.5% correctly acknowledged the need for imaging post-febrile UTI.

Referral criteria and kidney risk

Only 7.5% identified age <3 months as an indication for urgent referral – contrary to NICE and Royal Hospital guidelines recommending urgent specialist evaluation for infants <3 months due to sepsis and kidney injury risk.^[11,15] This hesitancy may stem from a lack of national PHC protocols or fear of referral rejection.^[4,23] From a nephrology perspective, delayed referral in this vulnerable group may theoretically increase the risk of acute kidney injury (AKI) and permanent kidney scarring based on established pathophysiological pathways,^[11,15] though this study did not directly measure kidney outcomes. Such delays could potentially contribute to increased tertiary care burden.

Antibiotic stewardship

The underuse of trimethoprim and nitrofurantoin (reported as avoided by >59%) in favor of broad-spectrum agents like amoxicillin/co-amoxiclav may reflect formulary limitations or knowledge gaps.^[2,24] The observed preference for amoxicillin/ co-amoxiclav over guideline-recommended narrow-spectrum agents may reflect local formulary availability, perceived resistance patterns, or habitual prescribing. Recent Omani surveillance data indicate Escherichia coli resistance to amoxicillin exceeds 60% in pediatric UTI isolates,^[2,9,25] underscoring the importance of stewardship-aligned prescribing. Inappropriate empirical therapy could increase the risk of treatment failure and recurrent pyelonephritis, which are primary drivers of kidney scarring. Furthermore, overuse of broad-spectrum antibiotics may contribute to regional resistance patterns, limiting future therapeutic options for complicated kidney infections.

Risk factor recognition

Constipation and neurological conditions (e.g., spinal lesions) were under-recognized (73–75%). These are critical risk factors for underlying uropathy and recurrent UTI.^[26,27] Failure to identify these conditions at the primary care level may delay diagnostic imaging and urological intervention, potentially permitting ongoing kidney damage.

Strengths and limitations

Strengths include robust instrument validation (CVR, pilot α), high response rate (90.4%), and focus on PHC – Oman’s frontline care tier. Limitations include: (1) Self-report bias, as GPs may have overestimated guideline adherence or underreported uncertain practices; (2) social desirability bias, wherein participants may have provided responses perceived as professionally appropriate; (3) lack of direct observation, as findings reflect stated preferences rather than audited clinical behavior or prescription records; (4) limited generalizability, as results pertain to Muscat PHCs and practices in rural governorates may differ; (5) absence of patient-level kidney outcome data, as no kidney scarring, AKI, CKD, referral timelines, or imaging results were measured – implications for kidney health are inferred from guideline frameworks and should not be interpreted as observed associations; and (6) cross-sectional design, which precludes assessment of temporal changes or causal inference.

Implications for nephrology

These findings support the development of a national PHC guideline for pediatric UTI, aligned with MoH priorities for antimicrobial stewardship and PHC strengthening.^[18] Integration into CME programs and undergraduate curricula is essential. Establishing clear referral pathways between PHC and nephrology/urology services may help ensure timely intervention for high-risk children, potentially supporting kidney function preservation and reducing the long-term burden of CKD in Oman.