Ten to the Five: 100,000 downloads

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Just a quick post to say Thank You to all our followers.  Your quiet enthusiasm inspires us!


We have just over 50 PEMcasts on EMPEM.org now, and our total downloads of mp3 podcasts has recently crossed the 100,000 mark.

We aim to keep them coming, so send us a comment to let us know what you’d like us to cover next…  Help us reach 1 million downloads!

Thanks for your support.

Cheers

Colin & pals

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Pediatric UTI Controversies

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So, you thought it was straightforward: suspect UTI, diagnose UTI, treat UTI
And let someone else worry about the follow-up.
Unfortunately, we work in a fragmented system, where we need to kick-start the correct follow-up for our patients, who may otherwise miss out if we don’t get them on the right track before they leave the Emergency Department.

We used to be paranoid about investigating Urinary Tract Infection in children.  Some of us still are, some of us are less worried, while some of us have not yet realised that kids are different, and are unaware that the Pediatricians out there have been aggressively investigating UTIs in kids for decades.  Maybe we can stop trying to educate and inform these laggards now?

Although the evidence is far from complete, the landscape of pediatric UTI is definitely changing, and the discussion is driving a less aggressive approach to investigating and following up UTI in children.  But are we swinging too far in the other direction?

Join us on a tour of the literature, and decide for yourself…


UTI Controversies PEMcast – Outline

[cp] Hello, disclaimer, introduction

[cp] Background

Common clinical problem, significant consequences if missed – some debate about this more recently.
Not clear what pre-requisites are for renal scarring – whether genetic predisposition, related to timing of infection and treatment, severity of infection.
Not clear whether renal scarring is preventable by a strategy of aggressive treatment and investigation.
Both the treatments and investigations come with associated risks, discomfort, and costs.

[AH] Controversies include:

  • When to treat with IV ABs
  • How long to treat
  • When to give prophylactic antimicrobials
  • Utility of proof-of-cure urine test
  • Who to investigate
  • How to investigate
  • Treatment of VUR

…because of a relative lack of RCT evidence.

[cp] Ideally we need to balance risks and costs of any tests/interventions against the likelihood of benefit to the patient, aiming to achieve ‘greatest good for the greatest number’ with our resources (or: spend more money to prevent any adverse outcomes).

We will not be able to definitively answer these questions, but aim to give a representative cross-section of opinion and a small amount of science to inform the debate…

Papers

[AH] NICE CG 54 (2007) (& RCH Melbourne interpretation)

http://www.nice.org.uk/CG54

http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5241
http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=15338

[SF] Coulthard 2008 (scarring)
http://www.ncbi.nlm.nih.gov/pubmed/19015216

[SF] Montini 2008 (Italian mob – prophylaxis RCT)
http://www.ncbi.nlm.nih.gov/pubmed/18977988

[AH] Craig 2009 NEJM (prophylaxis)
http://www.ncbi.nlm.nih.gov/pubmed/19864673

[cp] Mathews 2009 (VUR controversies)
http://www.ncbi.nlm.nih.gov/pubmed/19570724

[cp] Schroeder 2011 (validation of NICE)
http://www.ncbi.nlm.nih.gov/pubmed/22065183

[cp] Finnell 2011 (AAP Guideline, incorporating info from Montini & Craig):
Background:
http://www.ncbi.nlm.nih.gov/pubmed/21873694
Guideline:
http://pediatrics.aappublications.org/content/early/2011/08/24/peds.2011-1330.full.pdf+html

[SF] Tullus 2012 (Editorial, AAP vs NICE)
http://www.ncbi.nlm.nih.gov/pubmed/22203365

[all] Summary & best-guess recommendations

References

National Institute for Health and Clinical Excellence
Clinical Guideline CG 54: Urinary Tract Infection in Children
August 2007 http://www.nice.org.uk/CG54

Coulthard MG, Lambert HJ, Keir MJ.
Do systemic symptoms predict the risk of kidney scarring after urinary tract infection?
Arch Dis Child. 2009 Apr;94(4):278-81. doi: 10.1136/adc.2007.132290. Epub 2008 Nov 17. PubMed PMID: 19015216.

Montini G, Rigon L, Zucchetta P, Fregonese F, Toffolo A, Gobber D, Cecchin D, Pavanello L, Molinari PP, Maschio F, Zanchetta S, Cassar W, Casadio L, Crivellaro C, Fortunati P, Corsini A, Calderan A, Comacchio S, Tommasi L, Hewitt IK, Da Dalt L, Zacchello G, Dall’Amico R; IRIS Group.
Prophylaxis after first febrile urinary tract infection in children? A multicenter, randomized, controlled, noninferiority trial.
Pediatrics. 2008 Nov;122(5):1064-71. doi: 10.1542/peds.2007-3770. PubMed PMID: 18977988.

Craig JC, Simpson JM, Williams GJ, Lowe A, Reynolds GJ, McTaggart SJ, Hodson EM, Carapetis JR, Cranswick NE, Smith G, Irwig LM, Caldwell PH, Hamilton S, Roy LP; Prevention of Recurrent Urinary Tract Infection in Children with Vesicoureteric Reflux and Normal Renal Tracts (PRIVENT) Investigators.
Antibiotic prophylaxis and recurrent urinary tract infection in children.
N Engl J Med. 2009 Oct 29;361(18):1748-59. doi: 10.1056/NEJMoa0902295.
Erratum in: N Engl J Med. 2010 Apr 1;362(13):1250. PubMed PMID: 19864673.

Mathews R, Carpenter M, Chesney R, Hoberman A, Keren R, Mattoo T, Moxey-Mims M, Nyberg L, Greenfield S. Controversies in the management of vesicoureteral reflux: the rationale for the RIVUR study.
J Pediatr Urol. 2009 Oct;5(5):336-41. doi: 10.1016/j.jpurol.2009.05.010. Epub 2009 Jul 1. Review. PubMed PMID:
19570724; PubMed Central PMCID: PMC3163089.

Schroeder AR, Abidari JM, Kirpekar R, Hamilton JR, Kang YS, Tran V, Harris SJ.
Impact of a more restrictive approach to urinary tract imaging after febrile urinary tract infection.
Arch Pediatr Adolesc Med. 2011 Nov;165(11):1027-32. doi: 10.1001/archpediatrics.2011.178. PubMed PMID: 22065183.

Finnell SM, Carroll AE, Downs SM; Subcommittee on Urinary Tract Infection.
Technical report—Diagnosis and management of an initial UTI in febrile infants and young children.
Pediatrics. 2011 Sep;128(3):e749-70. doi: 10.1542/peds.2011-1332. Epub 2011 Aug 28. PubMed PMID: 21873694.

Subcommittee on Urinary Tract Infection and Steering Committee on Quality Improvement and Management.
Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months.
Pediatrics peds.2011-1330; published ahead of print August 28, 2011, doi:10.1542/peds.2011-1330
http://pediatrics.aappublications.org/content/early/2011/08/24/peds.2011-1330.full.pdf+html

Tullus K.
What do the latest guidelines tell us about UTIs in children under 2 years of age.
Pediatr Nephrol. 2012 Apr;27(4):509-11. doi: 10.1007/s00467-011-2077-5. Epub 2011 Dec 28. PubMed PMID: 22203365.

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UTI in children

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Urinary Tract Infections in kids are a recurring clinical question that bugs us as clinicians… Why is Urinary Tract Infection in children different from cystitis or pyelonephritis in adults? How hard should we be looking for UTI, and what’s the best way to confirm or exclude the diagnosis?

In this podcast we discuss the diagnosis, important differentials, and treatment of pediatric Urinary Tract Infection.


UTI PEMcast outline

[cp] Hello, disclaimer, introduction

[cp] Background

Common clinical problem, esp in FWS – urinalysis = most useful test

Significant consequences if missed

Controversies for discussion next episode (incl when to treat with IV Antibiotics, how long to treat, when to give prophylactic antimicrobials, proof-of-cure urine test, who to investigate, how to investigate, treatment of VUR)

[AH] Epidemiology (frequency in different age groups & genders, number of admissions) – approx 5% of FWS patients.

[SF] Aetiology (bacteria commonly involved) esp GI organisms – E coli, Klebsiella, Proteus, enterobacter, etc. Pseudomonas = more worrying.

Fastidious organisms eg mycobacteria
STIs (Chlamydia, gonorrhea)

[cp] Concepts / Definitions of:

UTI

Culture-proven vs presumed vs stricter definition (2 out of 3 cultures single-growth)

Cystitis vs pyelonephritis

Asymptomatic bacteriuria

Sterile pyuria

[AH] History

Fever (may frequently be the only symptom)

Dysuria, Frequency, Urgency (in toddlers and older kids)

Systemic upset

Vomiting

Neonates may have hypothermia; loose stools, vomiting, or just NQR

Background info (past medical history etc)

Recent antibiotic use

Shaikh et al JAMA 2007

[SF] Examination

General: well or sick, or Not Quite Right

Hydration, vital signs, fever (attention to measuring method)

Systems – alternative source of fever esp ENT, RS

Abdomen – tenderness (suprapubic / renal angle / RIF)

Perineum & genitalia (local inflammation)

Investigations

[cp] Bedside:

Glucose (DEFG)

Urine:

Collection methods (SPA, in-out catheter, clean-catch, pads (special ones), bag (never))

Cleaning for collection (thorough)

Urine clarity / colour / smell not reliable to exclude/confirm infection!

[AH] Urinalysis: limited sensitivity in under 12 months (leukocyte esterase test, bladder dwell time) – need urgent urine microscopy

Specificity <100% but combination of nitrite & leuks highly suggestive

Do not treat without sampling urine first!

[AH] Urine microscopy: helpful

>100 WBCs/hpf diagnostic (<20 normal), 20-100 less clear

(infants may have UTI without mounting WBC response in urine or blood initially)

RBCs often increased

Bacteria on microscopy – significant esp if all same type (gram-negative rods); mixed = usually contaminant

Epithelial cells >20 suggests contaminated sample

[SF] Urine Culture: Pure growth of single organism is diagnostic if > 100, 000 (10^5) / mL

Mixed growth usually contaminant, but in young infants, check whether one strain predominates (eg mostly E coli with few others)

Negative culture after 48 hours excludes UTI for practical purposes

[SF] Urine sensitivities (if positive culture) – target antibiotics more specifically (some antibiotics not tested, eg enterococci in-vitro sensitivity to Trimethoprim not predictive of in-vivo situation)

[cp] Bloods: if young or unwell: Blood Culture, FBC, CRP, U&E, glucose (others depending on clinical scenario)

CSF sampling in neonate as part of septic screen, even if UTI confirmed (E coli UTI -10% have meningitis) (CXR too if indicated?)

Imaging: not in ED (follow-up imaging – see later)

[AH] Differential Diagnosis:

Local inflammation: Vaginosis, vaginitis, balanitis

Urethritis (STIs)

Epididymo-orchitis

Neighbourhood syndrome eg appendicitis

Systemic infection (few WBCs in urine)

*** commonest = Contaminant (esp in diarrhea, bag samples, inadequate cleansing – epithelial cells)

[SF] Treatment:

Supportive care (esp in younger & unwell patients)

Specific treatment: antibiotics – empiric based on local resistance/sensitivity patterns, then specific based on culture sensitivities

[AH] Diposition:

Some controversy, one approach is to admit all systemically unwell patients, and admit all suspected UTIs under 6 months age, for IV antibiotics (?any role for middle road of admitting for observation, treating with oral antibiotics)

Follow-up:

[cp] Traditionally refer all males and all pre-pubertal females for follow-up with a General Pediatrician (they prefer culture-definite patients)

Some hospitals prefer U/S to be done prior to first clinic visit

[SF] Follow-up imaging controversial, may include U/S urinary tract, MCUG (in infants), DMSA scan, MAG-3 scan) All have different role / focus

Timing of U/S – swollen kidneys in first few weeks

[AH] Prophylactic antimicrobials also controversial – follow local policy

[all] Summary, Goodbye

References

Shaikh N, Morone NE, Lopez J, Chianese J, Sangvai S, D’Amico F, Hoberman A, Wald ER.
Does this child have a urinary tract infection?
JAMA. 2007 Dec 26;298(24):2895-904. Review.
PubMed PMID: 18159059.

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