Journal Club/July 31, 2009Journal Club/July 31, 2009. . Dore-Bergeron et al. Dore-Bergeron et al. Urinary tract infections in Urinary tract infections in 1-3 month old infants: 1-3 month old infants: ambulatory treatment with ambulatory treatment with intravenous antibioticsintravenous antibioticsDavid H. Rubin, MDDavid H. Rubin, MDChairman and Program Director, PediatricsChairman and Program Director, PediatricsSt Barnabas HospitalSt Barnabas HospitalProfessor of Clinical Pediatrics, Albert Einstein Professor of Clinical Pediatrics, Albert Einstein College of MedicineCollege of Medicine

OBJECTIVES OF OBJECTIVES OF SEMINARSEMINAR

AimAim

Hypothesis Hypothesis

Methods and statistical Methods and statistical strategiesstrategies

ConclusionConclusion

Competency based Competency based evaluationevaluation

COMPETENCY BASED EVALUATION

Review of competencies (pre-review of article)

Review of competencies (post-review of article)

Application of specific issues from article to each competency• Attempt to match issues from article

with specific competency

COMPETENCY COMPETENCY BASED OBJECTIVESBASED OBJECTIVES

Medical KnowledgeMedical Knowledge • knowledge about the established knowledge about the established

and evolving biomedical, clinical, and evolving biomedical, clinical, and cognate (epidemiological and and cognate (epidemiological and social-behavioral) sciences and social-behavioral) sciences and their application to patient caretheir application to patient care

COMPETENCY COMPETENCY BASED OBJECTIVESBASED OBJECTIVES

Patient CarePatient Care • family centered patient care family centered patient care

developmentally and age developmentally and age appropriate compassionate and appropriate compassionate and effective for treatment of health effective for treatment of health care problems and promotion of care problems and promotion of healthhealth

COMPETENCY COMPETENCY BASED OBJECTIVESBASED OBJECTIVES

Practice Based LearningPractice Based Learning • investigation and evaluation of investigation and evaluation of

patient care, and the assimilation patient care, and the assimilation of scientific evidenceof scientific evidence

Communication SkillsCommunication Skills • interpersonal and communication interpersonal and communication

skills resulting in effective skills resulting in effective information exchange and learning information exchange and learning with patients, families and with patients, families and professional associatesprofessional associates

COMPETENCY COMPETENCY BASED OBJECTIVESBASED OBJECTIVES

System Based PracticeSystem Based Practice • understanding systems of health understanding systems of health

care organization, financing, and care organization, financing, and delivery, and the relationship of delivery, and the relationship of one’s local practice and these one’s local practice and these larger systemslarger systems

ProfessionalismProfessionalism • carrying out professional carrying out professional

responsibilities, adherence to responsibilities, adherence to ethical principles, and sensitivity ethical principles, and sensitivity to diverse patient populationsto diverse patient populations

INTRODUCTIONINTRODUCTION Usual practice is to hospitalize young Usual practice is to hospitalize young

infants - especially those < 3 months of infants - especially those < 3 months of age with urinary tract infections due toage with urinary tract infections due to• Risk of bacteremia and other SBIRisk of bacteremia and other SBI• Risk of renal scarringRisk of renal scarring

““Ambulatory treatment of UTI in the Ambulatory treatment of UTI in the 3m-5 year group has been shown to be 3m-5 year group has been shown to be safe, feasible and satisfactory to safe, feasible and satisfactory to parents…”parents…”

No study of same topic to date in No study of same topic to date in younger age groupyounger age group

HYPOTHESIS/AIM OF HYPOTHESIS/AIM OF STUDYSTUDY

Specific challenges (e.g. IV access) Specific challenges (e.g. IV access) and reluctance of ED physicians to and reluctance of ED physicians to discharge home young infants with discharge home young infants with bacterial infections during the first bacterial infections during the first 24-48 hours of treatment could be 24-48 hours of treatment could be addressed with successful OPD addressed with successful OPD treatment with IV antibiotics in a treatment with IV antibiotics in a “day treatment center” in infants “day treatment center” in infants 1-3 months of age1-3 months of age

METHODS

Clinical protocol established in tertiary care Canadian hospital (Montreal) in 2005• Eligible: all children 30-90 days of age

with diagnosis of febrile UTI• LP? – at discretion of attending

physician• If non toxic appearing with normal

renal function, subjects received:

METHODS Single dose of IV gentamicin (2.5 or 5mg/kg)

given through IV catheter Single dose of IV ampicillin 2 or 3 doses of oral amoxicillin to be taken until

1st visit at DTC Parents measured rectal temperature every 4

hours during IV home therapy Exclusion criteria (these patients were

hospitalized)• Age < 30 days• Toxic appearing or dehydrated• Abnormal renal function• “Dubious parental compliance”• H/O renal surgery• Abnormal CSF findings• Serious medical conditions

METHODS

DTC• Open 7 days/week• Staffed by hospitalists• Treatment continued

• IV Gentamicin (5 mg/kg) Qday until “child was afebrile for ≥ 24 hours and urine culture results available”

• Oral amoxicillin discontinued when gram negative bacilli identified; after gentamicin treatment stopped, oral amoxicillin was continued for 10 days

If 1st UTI renal ultrasound and VCUG prior to DTC discharge

METHODS

“Retrospective cohort study” 1/1/2005-9/30/2007• Infants 1-3 months of age with first

UTI and history of fever in prior 48 hours or rectal temp ≥ 48 hours in the ED

• Admission rosters were reviewed to find patients for the study: admitting or discharge diagnosis of UTI or pyelonephritis in 1-3 month olds

METHODS

“Retrospective cohort study” 1/1/2005-9/30/2007• Definition of UTI

• Suprapubic: any gm negative bacteria or > 10 X 106 colonies/L or

• Catheterized: > 50 X 106 colonies/L of a single pathogen or 10 X 106 colonies/L of pseudomonas or

• Treating physician decided diagnosis was UTI

STATISTICAL ANALYSIS

Multivariate and logistic regression used to determine if age was associated with “successful implementation of treatment protocol.”

“Appropriateness” of patient referral tot DTC or hospital was a major outcome variable• Covariates: age ≤ 60 days, distance home to

hospital < 20km, ED physician experience ≤ 10 years, time of day

STATISTICAL ANALYSIS

“Successful treatment in the DTC”• Defined as: attendance at all visits,

resolution of fever within 48 hours, negative control urine culture and blood culture results, and no hospitalization

• Covariates: age ≤ 60 days, distance home to hospital < 20km, type of bacteria in urine culture (e coli v other bacteria)

RESULTS

See Figure 1 algorithm page 18 87% of infants (102/118) were

referred to appropriate site• 2 sent to DTC that should have been

hospitalized due to abnormal CSF See Table 1, page 19 Adherence to protocol lower for

younger patients (p>.05)

RESULTS

Diagnosis of UTI made for 86.6% of patients sent to DTC (see Table 2)

Clinical course of UTI – see Table 3, page 20

7 patients were hospitalized from DTC• 5/6 children with bacteremia• 1 with GERD• Right hydronephrosis

RESULTS

Treatment considered “successful” for 86.2% of patients treated in DTC

7/8 treatment failures defined as “failures” because they were admitted

Differences for success rates for younger v older groups (≤ 60 d v older) due to frequency of hospitalization for younger group

DISCUSSIONDISCUSSION

Ambulatory treatment of UTI for 30-90day old Ambulatory treatment of UTI for 30-90day old infants with febrile UTI’s with short term IV infants with febrile UTI’s with short term IV treatment is treatment is “feasible.”“feasible.”

““Treatment failures” (7/8) due to hospital Treatment failures” (7/8) due to hospital admission; patients usually admitted due to admission; patients usually admitted due to positive blood cultures and were not clinically positive blood cultures and were not clinically unstableunstable

Need to complete VCUG and sonogram soon to Need to complete VCUG and sonogram soon to rule out potential pathologyrule out potential pathology

Prior studies looking at oral antibiotics for Prior studies looking at oral antibiotics for febrile UTI did not include younger populationfebrile UTI did not include younger population

DISCUSSIONDISCUSSION

LimitationsLimitations• ?Generalizability of findings ?Generalizability of findings

• LocationLocation• Population of participantsPopulation of participants

• ?Long term followup?Long term followup• How was the definition of “success” created?How was the definition of “success” created?• Attending physician had option to assign Attending physician had option to assign

diagnosis of UTI without any laboratory diagnosis of UTI without any laboratory evidenceevidence

DISCUSSIONDISCUSSION Strengths of the studyStrengths of the study

• Interesting question, importantInteresting question, important Weaknesses of the studyWeaknesses of the study

• Population very different Population very different (generalizability limited); impossible (generalizability limited); impossible to perform in NYCto perform in NYC

• Author excluded parents who were Author excluded parents who were “dubious” “dubious”

COMPETENCY COMPETENCY BASED OBJECTIVESBASED OBJECTIVES

Medical KnowledgeMedical Knowledge • knowledge about the established knowledge about the established

and evolving biomedical, clinical, and evolving biomedical, clinical, and cognate (epidemiological and and cognate (epidemiological and social-behavioral) sciences and social-behavioral) sciences and their application to patient caretheir application to patient care

• Treatment of febrile UTI in childrenTreatment of febrile UTI in children

COMPETENCY COMPETENCY BASED OBJECTIVESBASED OBJECTIVES

Patient CarePatient Care • family centered patient care family centered patient care

developmentally and age developmentally and age appropriate compassionate and appropriate compassionate and effective for treatment of health effective for treatment of health care problems and promotion of care problems and promotion of healthhealth

• Parents may not understand issues Parents may not understand issues surrounding UTI’ssurrounding UTI’s

COMPETENCY COMPETENCY BASED OBJECTIVESBASED OBJECTIVES

Practice Based LearningPractice Based Learning • investigation and evaluation of patient investigation and evaluation of patient

care, and the assimilation of scientific care, and the assimilation of scientific evidenceevidence

• Scientific evaluation of hypothesis, methods, Scientific evaluation of hypothesis, methods, and conclusion of articleand conclusion of article

Communication SkillsCommunication Skills • interpersonal and communication skills interpersonal and communication skills

resulting in effective information resulting in effective information exchange and learning with patients, exchange and learning with patients, families and professional associatesfamilies and professional associates

• Parental education and support criticalParental education and support critical

COMPETENCY COMPETENCY BASED OBJECTIVESBASED OBJECTIVES

System Based PracticeSystem Based Practice • understanding systems of health care understanding systems of health care

organization, financing, and delivery, and organization, financing, and delivery, and the relationship of one’s local practice and the relationship of one’s local practice and these larger systemsthese larger systems

• Who gets admitted and who will pay for this?Who gets admitted and who will pay for this?Admission warranted on medical reasons? Admission warranted on medical reasons?

ProfessionalismProfessionalism • carrying out professional responsibilities, carrying out professional responsibilities,

adherence to ethical principles, and adherence to ethical principles, and sensitivity to diverse patient populationssensitivity to diverse patient populations

• Patient education in diverse culturesPatient education in diverse cultures