1
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Marsh MC, Junquera GY, Stonebrook E, Spencer JD, Watson JR. Urinary Tract Infections in Children. Pediatr Rev 2024; 45:260-270. [PMID: 38689106 DOI: 10.1542/pir.2023-006017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
Despite the American Academy of Pediatrics guidelines for the evaluation, treatment, and management of urinary tract infections (UTIs), UTI diagnosis and management remains challenging for clinicians. Challenges with acute UTI management stem from vague presenting signs and symptoms, diagnostic uncertainty, limitations in laboratory testing, and selecting appropriate antibiotic therapy in an era with increasing rates of antibiotic-resistant uropathogens. Recurrent UTI management remains difficult due to an incomplete understanding of the factors contributing to UTI, when to assess a child with repeated infections for kidney and urinary tract anomalies, and limited prevention strategies. To help reduce these uncertainties, this review provides a comprehensive overview of UTI epidemiology, risk factors, diagnosis, treatment, and prevention strategies that may help pediatricians overcome the challenges associated with acute and recurrent UTI management.
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Affiliation(s)
- Melanie C Marsh
- Division of Hospital Medicine, Department of Pediatrics, Advocate Aurora Atrium Health Systems, Chicago, IL
| | - Guillermo Yepes Junquera
- Kidney and Urinary Tract Center, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
- Division of Infectious Diseases
| | - Emily Stonebrook
- Kidney and Urinary Tract Center, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
- Division of Nephrology and Hypertension, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
| | - John David Spencer
- Kidney and Urinary Tract Center, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
- Division of Nephrology and Hypertension, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
| | - Joshua R Watson
- Center for Clinical Excellence, Nationwide Children's Hospital, Columbus, OH
- Division of Infectious Diseases
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2
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Files JM. Fever in infants ages 8 to 60 days: An updated guideline for evaluation. JAAPA 2024; 37:30-33. [PMID: 38230907 DOI: 10.1097/01.jaa.0000997684.82826.5d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
ABSTRACT Fever in infants under age 60 days is a leading cause of ED, urgent care, and primary care visits. Most infants present as well-appearing, and guidelines for the workup and appropriate management of these children have varied over the decades. Additionally, testing availability, accuracy, and changing bacterial prevalence patterns have rendered many guidelines obsolete. An updated guideline from the American Academy of Pediatrics provides a foundation for clinician evaluation of patients in this vulnerable age group.
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Affiliation(s)
- Jared M Files
- Jared M. Files practices in emergency medicine at Marian Regional Medical Center in Santa Maria, Calif., and at the Southern Arizona VA Healthcare System in Tucson Ariz., and in urgent care at Cottage Health in Santa Barbara, Calif. The author has disclosed no potential conflicts of interest, financial or otherwise
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3
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Wang ME, Jones VG, Kane M, Allan JM, Maleknia L, Patel R, Ip W, Newman TB, Roberts KB, Schroeder AR. Clinical Course of Children 1 to 24 Months Old With Positive Urine Cultures Without Pyuria. Acad Pediatr 2024; 24:111-118. [PMID: 37354950 DOI: 10.1016/j.acap.2023.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 06/07/2023] [Accepted: 06/15/2023] [Indexed: 06/26/2023]
Abstract
OBJECTIVE To describe the clinical course of children with positive urine cultures without pyuria who were not given antibiotics initially, identify predictors of subsequent antibiotic treatment, and evaluate the association between subsequent treatment and urinary tract infection (UTI) within 30 days. METHODS We conducted a multicenter retrospective cohort study of children 1 to 24 months old who had positive urine cultures without pyuria and who were not started on antibiotics upon presentation to 3 health care systems from 2010 to 2021. Outcomes included clinical status at the time urine cultures resulted, escalation of care (emergency department visit or hospitalization) and subsequent antibiotic treatment within 7 days, and subsequent UTI within 30 days of presentation. RESULTS Of 202 included children, 61% were female and median age was 9 months. Of 151 patients with clinical status information when cultures resulted, 107 (70.8%, 95% confidence interval [CI] 62.9-77.9%) were improved. Two of 202 children (1.0%, 95% CI 0.2-4.0%) experienced care escalation. Antibiotics were started in 142 (82.2%) children, and treatment was associated with prior UTI (risk ratio [RR] 1.20, 95% CI 1.15-1.26) and lack of improvement (RR 1.22, 95% CI 1.13-1.33). Subsequent UTI was diagnosed in 2 of 164 (1.2%, 95% CI 0.1-4.3%) treated and 0 of 36 (0%, 95% CI 0-9.7%) untreated children. CONCLUSIONS Seventy percent of children with positive urine cultures without pyuria improved before starting antibiotics; however, >80% were ultimately treated. Future research should study the impact of diagnostic stewardship interventions and various urine testing strategies to optimize the management of children evaluated for UTI.retain-->.
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Affiliation(s)
- Marie E Wang
- Division of Pediatric Hospital Medicine (ME Wang, W Ip, and AR Schroeder), Stanford University School of Medicine, Palo Alto, Calif.
| | - Veena G Jones
- Division of Pediatric Hospital Medicine (VG Jones and JM Allan), Palo Alto Medical Foundation, Palo Alto, Calif.
| | - Miranda Kane
- Department of Pediatric Hospital Medicine (M Kane, L Maleknia, and R Patel), Kaiser Permanente Northern California, Oakland, Calif.
| | - Jessica M Allan
- Division of Pediatric Hospital Medicine (VG Jones and JM Allan), Palo Alto Medical Foundation, Palo Alto, Calif.
| | - Lydia Maleknia
- Department of Pediatric Hospital Medicine (M Kane, L Maleknia, and R Patel), Kaiser Permanente Northern California, Oakland, Calif.
| | - Ritu Patel
- Department of Pediatric Hospital Medicine (M Kane, L Maleknia, and R Patel), Kaiser Permanente Northern California, Oakland, Calif.
| | - Wui Ip
- Division of Pediatric Hospital Medicine (ME Wang, W Ip, and AR Schroeder), Stanford University School of Medicine, Palo Alto, Calif.
| | - Thomas B Newman
- Departments of Epidemiology & Biostatistics and Pediatrics (TB Newman), University of California, San Francisco.
| | - Kenneth B Roberts
- Department of Pediatrics (KB Roberts), University of North Carolina at Chapel Hill.
| | - Alan R Schroeder
- Division of Pediatric Hospital Medicine (ME Wang, W Ip, and AR Schroeder), Stanford University School of Medicine, Palo Alto, Calif.
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4
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Ostrow O, Prodanuk M, Foong Y, Singh V, Morrissey L, Harvey G, Campigotto A, Science M. Decreasing Misdiagnoses of Urinary Tract Infections in a Pediatric Emergency Department. Pediatrics 2022; 150:188353. [PMID: 35773521 DOI: 10.1542/peds.2021-055866] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/29/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Urinary tract infection (UTI) is a common diagnosis in the emergency department (ED), often resulting in empirical antibiotic treatment before culture results. Diagnosis of a UTI, particularly in children, can be challenging and misdiagnosis is common. The aim of this initiative was to decrease the misdiagnosis of uncomplicated pediatric UTIs by 50% while improving antimicrobial stewardship in the ED over 4 years. METHODS By using the Model for Improvement, 3 interventions were developed: (1) an electronic UTI diagnostic algorithm, (2) a callback system, and (3) a standardized discharge antibiotic prescription. Outcome measures included the percentage of patients with UTI misdiagnosis (prescribed antibiotics, but urine culture results negative) and antibiotic days saved. As a balancing measure, positive urine culture results without a UTI diagnosis were reviewed for ED return visits or hospitalization. Statistical process control and run charts were used for analysis. RESULTS From 2017 to 2021, the mean UTI misdiagnosis decreased from 54.6% to 26.4%. The adherence to the standardized antibiotic duration improved from 45.1% to 84.6%. With the callback system, 2128 antibiotic days were saved with a median of 89% of patients with negative culture results contacted to discontinue antibiotics. Of 186 patients with positive urine culture results with an unremarkable urinalysis, 14 returned to the ED, and 2 were hospitalized for multiresistant organism UTI treatment. CONCLUSIONS A UTI diagnostic algorithm coupled with a callback system safely reduced UTI misdiagnoses and antibiotic usage. Embedding these interventions electronically as a decision support tool, targeted audit and feedback, reminders, and education all supported long-term sustainability.
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Affiliation(s)
- Olivia Ostrow
- Division of Pediatric Emergency Medicine, Department of Pediatrics.,Departments of Pediatrics
| | - Michael Prodanuk
- Division of Pediatric Medicine, Department of Pediatrics.,Departments of Pediatrics
| | - Yen Foong
- Division of Pediatric Medicine, Department of Pediatrics.,Departments of Pediatrics
| | - Valene Singh
- Division of Pediatric Medicine, Department of Pediatrics.,Departments of Pediatrics
| | - Laura Morrissey
- Division of Pediatric Emergency Medicine, Department of Pediatrics.,Departments of Pediatrics
| | - Greg Harvey
- Division of Pediatric Emergency Medicine, Department of Pediatrics.,Departments of Pediatrics
| | - Aaron Campigotto
- Division of Microbiology, Department of Pediatric Laboratory Medicine.,Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Science
- Division of Infectious Disease, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Departments of Pediatrics
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5
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Lubell TR, Barasch JM, King B, Ochs J, Fan W, Duong J, Chitre M, Dayan P. Urinary tract infections in children: Testing a novel, noninvasive, point-of-care diagnostic marker. Acad Emerg Med 2022; 29:326-333. [PMID: 34665891 PMCID: PMC9199382 DOI: 10.1111/acem.14402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 10/08/2021] [Accepted: 10/18/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Urinary neutrophil gelatinase-associated lipocalin (uNGAL) appears highly accurate to identify urinary tract infections (UTIs) when obtained via catheterization. Our primary aim was to determine the agreement in uNGAL levels between paired catheter and bag urine specimens. Our secondary aim was to compare the diagnostic test characteristics of quantitative uNGAL, dipstick uNGAL (a potential point-of-care test), and urinalysis (UA). METHODS This was a prospective study of febrile children < 24 months evaluated for UTIs. We evaluated quantitative uNGAL at a previously identified threshold of 39.1 ng/mL, dipstick uNGAL at its built-in threshold of >50 ng/mL, and UA at standard thresholds for leukocyte esterase (LE). A positive urine culture was defined as >100,000 CFUs/mL of a pathogen. RESULTS A total of 211 patients were included (10% with positive urine cultures); 116 had paired catheterized and bagged samples. The agreement between catheterized and bagged samples at a quantitative uNGAL cutoff of ≥39.1 ng/mL was 0.76 (95% confidence interval [CI] = 0.67 to 0.83) and 0.77 (95% CI = 0.68 to 0.84) at a uNGAL dipstick threshold of >50 ng/mL. The area under the receiver operating characteristic curve for uNGAL from a catheterized sample was 0.96 (95% CI = 0.89 to 1.00) compared to 0.93 (95% CI = 0.87 to -0.99) from a bagged sample. The sensitivities of catheterized sample quantitative and dipstick uNGAL (90.5%) were higher than UA at a LE threshold of ≥1+ (57.1%). Bagged-sample uNGAL had lower quantitative and dipstick specificities (both 73.8%) than from catheterized samples (94.3% and 95.3% respectively), similar to UA. CONCLUSIONS uNGAL from bagged and catheterized samples showed insufficient agreement to be used interchangeably. The low specificity of uNGAL from bagged samples suggests that sampling technique affects uNGAL levels.
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Affiliation(s)
- Tamar R. Lubell
- Department of Emergency Medicine Division of Pediatric Emergency Medicine Columbia University Vagelos College of Physicians and Surgeons New York New York USA
| | - Jonathan M. Barasch
- Departments of Medicine and Pathology and Cell Biology Division of Nephrology Columbia University Vagelos College of Physicians and Surgeons New York New York USA
| | - Benjamin King
- Department of Pediatrics Columbia University Vagelos College of Physicians and Surgeons New York New York USA
- Department of Primary Care Weill Cornell Medicine New York New York USA
| | - Julie B. Ochs
- Department of Emergency Medicine Division of Pediatric Emergency Medicine Columbia University Vagelos College of Physicians and Surgeons New York New York USA
- College of Osteopathic Medicine New York Institute of Technology Old Westbury New York USA
| | - Weijia Fan
- Department of Biostatistics Mailman School of Public Health Columbia University New York New York USA
| | - Jimmy Duong
- Department of Biostatistics Mailman School of Public Health Columbia University New York New York USA
| | - Manasi Chitre
- Department of Emergency Medicine Division of Pediatric Emergency Medicine Columbia University Vagelos College of Physicians and Surgeons New York New York USA
- Department of Pediatrics Division of Pediatric Emergency Medicine Albert Einstein College of Medicine Bronx New York USA
| | - Peter S. Dayan
- Department of Emergency Medicine Division of Pediatric Emergency Medicine Columbia University Vagelos College of Physicians and Surgeons New York New York USA
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6
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Fatemi Y, Bergl PA. Diagnostic Stewardship: Appropriate Testing and Judicious Treatments. Crit Care Clin 2021; 38:69-87. [PMID: 34794632 DOI: 10.1016/j.ccc.2021.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Diagnostic stewardship encompasses the entire diagnosis-to-treatment paradigm in the intensive care unit (ICU). Initially born of the antimicrobial stewardship movement, contemporary diagnostic stewardship aims to promote timely and appropriate diagnostic testing that directly links to management decisions. In the stewardship framework, excessive diagnostic testing in low probability cases is discouraged due to its tendency to generate false-positive results, which have their own downstream consequences. Though the evidence basis for diagnostic stewardship initiatives in the ICU is nascent and largely limited to retrospective analyses, available literature generally suggests that these initiatives are safe, feasible, and associated with similar patient outcomes. As diagnostic testing of critically ill patients becomes increasingly sophisticated in the ensuing decade, a stewardship mindset will aid bedside clinicians in interpreting and incorporating new diagnostic strategies in the ICU.
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Affiliation(s)
- Yasaman Fatemi
- Division of Infectious Diseases, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA.
| | - Paul A Bergl
- Department of Critical Care, Gundersen Lutheran Medical Center, 1900 South Avenue, Mail Stop LM3-001, La Crosse, WI 54601, USA; Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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7
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Pantell RH, Roberts KB, Adams WG, Dreyer BP, Kuppermann N, O'Leary ST, Okechukwu K, Woods CR. Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old. Pediatrics 2021; 148:peds.2021-052228. [PMID: 34281996 DOI: 10.1542/peds.2021-052228] [Citation(s) in RCA: 174] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
This guideline addresses the evaluation and management of well-appearing, term infants, 8 to 60 days of age, with fever ≥38.0°C. Exclusions are noted. After a commissioned evidence-based review by the Agency for Healthcare Research and Quality, an additional extensive and ongoing review of the literature, and supplemental data from published, peer-reviewed studies provided by active investigators, 21 key action statements were derived. For each key action statement, the quality of evidence and benefit-harm relationship were assessed and graded to determine the strength of recommendations. When appropriate, parents' values and preferences should be incorporated as part of shared decision-making. For diagnostic testing, the committee has attempted to develop numbers needed to test, and for antimicrobial administration, the committee provided numbers needed to treat. Three algorithms summarize the recommendations for infants 8 to 21 days of age, 22 to 28 days of age, and 29 to 60 days of age. The recommendations in this guideline do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
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Affiliation(s)
- Robert H Pantell
- Department of Pediatrics, School of Medicine, University of California San Francisco, San Francisco, California
| | - Kenneth B Roberts
- Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - William G Adams
- Boston Medical Center/Boston University School of Medicine, Deparment of Pediatrics, Boston, Massachusetts
| | - Benard P Dreyer
- Department of Pediatrics, NYU Grossman School of Medicine, New York, New York
| | - Nathan Kuppermann
- Department of Emergency Medicine and Pediatric, School of Medicine, University of California, Davis School of Medicine, Sacramento, California
| | - Sean T O'Leary
- Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
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Liang T, Schibeci Oraa S, Rebollo Rodríguez N, Bagade T, Chao J, Sinert R. Predicting Urinary Tract Infections With Interval Likelihood Ratios. Pediatrics 2021; 147:peds.2020-015008. [PMID: 33277351 DOI: 10.1542/peds.2020-015008] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/03/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Protocols for diagnosing urinary tract infection (UTI) often use arbitrary cutoff values of urinalysis components to guide management. Interval likelihood ratios (ILRs) of urinalysis results may improve the test's precision in predicting UTIs. We calculated the ILR of urinalysis components to estimate the posttest probabilities of UTIs in young children. METHODS Review of 2144 visits to the pediatric emergency department of an urban academic hospital from December 2011 to December 2019. Inclusion criteria were age <2 years and having a urinalysis and urine culture sent. ILR boundaries for hemoglobin, protein, and leukocyte esterase were "negative," "trace," "1+," "2+" and "3+." Nitrite was positive or negative. Red blood cells and white blood cells (WBCs) were 0 to 5, 5 to 10, 10 to 20, 20 to 50, 50 to 100, and 100 to 250. Bacteria counts ranged from negative to "loaded." ILRs for each component were calculated and posttest probabilities for UTI were estimated. RESULTS The UTI prevalence was 9.2%, with the most common pathogen being Escherichia coli (75.2%). The ILR for leukocyte esterase ranged from 0.20 (negative) to 37.68 (3+) and WBCs ranged from 0.24 (0-5 WBCs) to 47.50 (100-250 WBCs). The ILRs for nitrites were 0.76 (negative) and 25.35 (positive). The ILR for negative bacteria on urinalysis was 0.26 and 14.04 for many bacteria. CONCLUSIONS The probability of UTI in young children significantly increases with 3+ leukocyte esterase, positive nitrite results, 20 to 50 or higher WBCs, and/or many or greater bacteria on urinalysis. The probability of UTI only marginally increases with trace or 1+ leukocyte esterase or 5 to 20 WBCs. Our findings can be used to more accurately predict the probability of true UTI in children.
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Affiliation(s)
- Tian Liang
- The State University of New York Downstate Medical Center, Brooklyn, New York; and .,New York City Health and Hospitals/Kings County, Brooklyn, New York
| | - Silvia Schibeci Oraa
- The State University of New York Downstate Medical Center, Brooklyn, New York; and.,New York City Health and Hospitals/Kings County, Brooklyn, New York
| | - Naomi Rebollo Rodríguez
- The State University of New York Downstate Medical Center, Brooklyn, New York; and.,New York City Health and Hospitals/Kings County, Brooklyn, New York
| | - Tanvi Bagade
- The State University of New York Downstate Medical Center, Brooklyn, New York; and.,New York City Health and Hospitals/Kings County, Brooklyn, New York
| | - Jennifer Chao
- The State University of New York Downstate Medical Center, Brooklyn, New York; and.,New York City Health and Hospitals/Kings County, Brooklyn, New York
| | - Richard Sinert
- The State University of New York Downstate Medical Center, Brooklyn, New York; and.,New York City Health and Hospitals/Kings County, Brooklyn, New York
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9
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Mulcrone AE, Parikh M, Ahmad FA. Reducing infant catheterization in the emergency department through clean-catch urine collection. J Am Coll Emerg Physicians Open 2020; 1:1533-1541. [PMID: 33392562 PMCID: PMC7771792 DOI: 10.1002/emp2.12211] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 07/10/2020] [Accepted: 07/14/2020] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE Our emergency department (ED) traditionally relied on urethral catheterization to obtain urine cultures when evaluating infants for urinary tract infections (UTIs). Catheterization is associated with adverse effects, and recent studies have demonstrated clean-catch urine methods can be successfully used to obtain urine cultures. We pursued a quality improvement (QI) initiative aimed at decreasing the frequency of urethral catheterizations in our ED by using an established clean-catch technique to obtain infant urine cultures. METHODS We implemented a clean-catch urine collection method, which we entitled "Bladder Massage," for infants 0-6 months of age needing a urine culture in our ED. Exclusions included critical illness, known urologic abnormality, or prior UTI diagnosis. Our primary interventions were educational initiatives. We retrospectively collected data regarding the use of bladder massage. Our balancing measure was the contamination rate of urine cultures obtained via bladder massage technique compared to catheterization. RESULTS In our first-year post-implementation, we identified 334 eligible patients. Bladder massage was attempted on 136/334 (40.7%) eligible infants, with 87/136 (64%) successful attempts, thus avoiding catheterization in 26.1% of patients. Our baseline contamination rate from catheterization was 8/488 (1.6%), compared to 10/87 (12%) using bladder massage (P < 0.001), with 9/10 contaminants from female patients. CONCLUSION We successfully introduced a method for clean-catch urine cultures in our pediatric ED, averting the need for urethral catheterization in many well-appearing infants. Ongoing efforts must focus on reduction of contamination in females, increased technique usage, and electronic health record changes to facilitate documentation to continue method use.
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Affiliation(s)
- Amanda E. Mulcrone
- Department of PediatricsWashington University School of Medicine in St. LouisSt. LouisMissouriUSA
- St. Louis Children's HospitalSt. LouisMissouriUSA
- Department of PediatricsBaylor College of MedicineSection of Emergency MedicineHoustonTexasUSA
| | - Manas Parikh
- Department of PediatricsWashington University School of Medicine in St. LouisSt. LouisMissouriUSA
- St. Louis Children's HospitalSt. LouisMissouriUSA
- Erie Family Health CenterChicagoIllinoisUSA
| | - Fahd A. Ahmad
- Department of PediatricsWashington University School of Medicine in St. LouisSt. LouisMissouriUSA
- St. Louis Children's HospitalSt. LouisMissouriUSA
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10
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Ohnishi T, Asada N, Furuichi M, Sekiguchi S, Awazu M, Hori N, Kamimaki I. A novel screening method for pediatric urinary tract infection using ordinary diapers. Sci Rep 2020; 10:19342. [PMID: 33168907 PMCID: PMC7652829 DOI: 10.1038/s41598-020-76405-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 10/22/2020] [Indexed: 11/11/2022] Open
Abstract
Urinary tract infection (UTI) is one of the most common bacterial infections in children. The symptoms of UTI in young children are nonspecific, therefore urine should be examined whenever UTI cannot be ruled out. In clinical settings, however, collecting urine from children who are not toilet trained is sometimes difficult, presenting a challenge in UTI management. Here, we developed a “diaper UTI test”, which enables the quick detection of pyuria in ordinary diapers, and investigated its sensitivity and specificity in a clinical study. The diaper UTI test is based on a leukocyte esterase reaction. Reagent was prepared in liquid form so that it can be absorbed by disposable diapers, where it will produce a violet color in the presence of pyuria. For the clinical study, we enrolled children younger than 3 years with potential UTI who underwent bladder catheterization for urine culture and urinalysis. Of the 65 children included, 21 were diagnosed with UTI. The sensitivity and specificity of the diaper UTI test were 90.5% (95% CI 69.6–98.8) and 93.2% (95% CI 81.3–98.6), respectively. Because of its convenience and good sensitivity, the diaper UTI test may be useful in the screening of pediatric UTI.
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Affiliation(s)
- Takuma Ohnishi
- Department of Pediatrics, National Hospital Organization Saitama Hospital, Saitama, Japan
| | - Nariaki Asada
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan. .,Department of Pediatrics, SUBARU Health Insurance Society Ota Memorial Hospital, Gunma, Japan.
| | - Munehiro Furuichi
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | | | - Midori Awazu
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Naoaki Hori
- Department of Pediatrics, SUBARU Health Insurance Society Ota Memorial Hospital, Gunma, Japan
| | - Isamu Kamimaki
- Department of Pediatrics, National Hospital Organization Saitama Hospital, Saitama, Japan
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11
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Standardizing Preoperative Evaluation for Pediatric Central Venous Access: A Care Algorithm to Improve Safety. JOURNAL OF INFUSION NURSING 2020; 43:262-274. [PMID: 32881813 DOI: 10.1097/nan.0000000000000386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Central vascular access device (CVAD) placement is a common procedure in children. When selecting a CVAD, available evidence and specified indications should be used to choose the device that best supports the patient's treatment and carries the lowest risks. A multidisciplinary team developed a care algorithm to standardize preoperative screening before pediatric CVAD placement, with 3 major parts: CVAD selection, patient risk stratification, and preoperative evaluation. Using a stepwise approach of provider education and incorporation into the electronic health record, the team achieved 82% stratification among inpatients. The team's algorithm integrates the existing literature and recommendations for safe and effective CVAD placement.
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12
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Shaikh N. Reply. J Pediatr 2020; 223:229-230. [PMID: 32580893 DOI: 10.1016/j.jpeds.2020.04.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 04/22/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Nader Shaikh
- Division of General Academic Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania
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13
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Patel N, Farooqi A, Callaghan M, Sethuraman U. Urinary Tract Infection in Febrile Children with Sickle Cell Disease Who Present to the Emergency Room with Fever. J Clin Med 2020; 9:jcm9051531. [PMID: 32438767 PMCID: PMC7290819 DOI: 10.3390/jcm9051531] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/01/2020] [Accepted: 05/08/2020] [Indexed: 11/18/2022] Open
Abstract
Sickle cell disease (SCD) patients are thought to be at higher risk for urinary tract infections (UTIs) compared to the general population secondary to increased sickling, abnormal urinary acidification, and an inability to concentrate the urine. The incidence of UTI in febrile children with SCD in the United States is unknown. Our objectives were to determine the rate of UTI among febrile SCD children and describe the risk factors for UTI in this population. We conducted a retrospective chart review of all febrile SCD patients <4 years of age who presented to a pediatric emergency department from 2012–2017 and who had a sterile sample of urine for analysis. A total of 167 febrile patients with SCD with 464 visits were identified. The majority were African American (95.2%), female (58.7%), and had hemoglobin SS (HbSS) (65.3%). The rate of UTI was 4.1%. All patients with a UTI were African American females with a median age of 19 months (IQR 12–30). On regression analysis, no risk factors were associated with a UTI. We found the rate of UTI in febrile young children with SCD was comparable to non-SCD children. Larger studies are required to identify the presence of risk factors for UTI in this population.
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Affiliation(s)
- Nehal Patel
- Division of Emergency Medicine, Carman and Ann Adams Department of Pediatrics, Children’s Hospital of MI, Detroit, MI 48201, USA;
- Correspondence: ; Tel.: +1-(313)-745-5260
| | - Ahmad Farooqi
- Children’s Research Center of MI, Wayne State University School of Medicine, Detroit, MI 48201, USA;
| | - Michael Callaghan
- Division of Pediatric Hematology and Oncology, Carman and Ann Adams Department of Pediatrics, Children’s Hospital of MI, Detroit, MI 48201, USA;
| | - Usha Sethuraman
- Division of Emergency Medicine, Carman and Ann Adams Department of Pediatrics, Children’s Hospital of MI, Detroit, MI 48201, USA;
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14
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Ammenti A, Alberici I, Brugnara M, Chimenz R, Guarino S, La Manna A, La Scola C, Maringhini S, Marra G, Materassi M, Morello W, Nicolini G, Pennesi M, Pisanello L, Pugliese F, Scozzola F, Sica F, Toffolo A, Montini G. Updated Italian recommendations for the diagnosis, treatment and follow-up of the first febrile urinary tract infection in young children. Acta Paediatr 2020; 109:236-247. [PMID: 31454101 PMCID: PMC7004047 DOI: 10.1111/apa.14988] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 08/22/2019] [Accepted: 08/23/2019] [Indexed: 12/21/2022]
Abstract
AIM Our aim was to update the recommendations for the diagnosis, treatment and follow-up of the first febrile urinary tract infection in young children, which were endorsed in 2012 by the Italian Society of Pediatric Nephrology. METHODS The Italian recommendations were revised on the basis of a review of the literature published from 2012 to October 2018. We also carried out an ad hoc evaluation of the risk factors to identify children with high-grade vesicoureteral reflux or renal scarring, which were published in the previous recommendations. When evidence was not available, the working group held extensive discussions, during various meetings and through email exchanges. RESULTS Four major modifications have been introduced. The method for collecting urine for culture and its interpretation has been re-evaluated. We have reformulated the algorithm that guides clinical decisions to proceed with voiding cystourethrography. The suggested antibiotics have been revised, and we have recommended further restrictions of the use of antibiotic prophylaxis. CONCLUSION These updated recommendations have now been endorsed by the Italian Society of Pediatric Nephrology and the Italian Society for Pediatric Infectivology. They can also be used to compare other recommendations that are available, as a worldwide consensus in this area is still lacking.
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Affiliation(s)
- Anita Ammenti
- Pediatric Polyspecialistic GroupPoliambulatorio Medi‐SaluserParmaItaly
| | - Irene Alberici
- Department of Woman and Child's HealthUniversity of PadovaPadovaItaly
| | | | - Roberto Chimenz
- Pediatric Nephrology and Dialysis UnitDepartment of PediatricsG. Martino HospitalUniversity of MessinaMessinaItaly
| | - Stefano Guarino
- Department of WomanChild and of General and Specialized SurgeryUniversità degli Studi della Campania L. VanvitelliNaplesItaly
| | - Angela La Manna
- Department of WomanChild and of General and Specialized SurgeryUniversità degli Studi della Campania L. VanvitelliNaplesItaly
| | - Claudio La Scola
- Nephrology and Dialysis UnitDepartment of PediatricsAzienda Ospedaliero Universitaria Sant'Orsola‐MalpighiBolognaItaly
| | | | - Giuseppina Marra
- Pediatric NephrologyDialysis and Transplant UnitFondazione Ca'Granda, IRCCS Policlinico di MilanoMilanoItaly
| | | | - William Morello
- Pediatric NephrologyDialysis and Transplant UnitFondazione Ca'Granda, IRCCS Policlinico di MilanoMilanoItaly
| | | | - Marco Pennesi
- Department of PediatricsInstitute for Child and Maternal HealthIRCCS Burlo GarofoloTriesteItaly
| | | | | | | | | | | | - Giovanni Montini
- Pediatric NephrologyDialysis and Transplant UnitFondazione Ca'Granda, IRCCS Policlinico di MilanoMilanoItaly
- Giuliana and Bernardo Caprotti Chair of PediatricsDepartment of Clinical Sciences and Community HealthUniversity of MilanoMilanoItaly
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An Ambulatory Antimicrobial Stewardship Initiative to Improve Diagnosis and Treatment of Urinary Tract Infections in Children. Jt Comm J Qual Patient Saf 2019; 45:829-837. [DOI: 10.1016/j.jcjq.2019.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 08/08/2019] [Accepted: 08/09/2019] [Indexed: 11/19/2022]
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Lendner I, Justman N, Givon-Lavi N, Maimon MS, Kestenbaum I, Ben-Shimol S. Urine dipstick low sensitivity for UTI diagnosis in febrile infants*. Infect Dis (Lond) 2019; 51:764-771. [DOI: 10.1080/23744235.2019.1652339] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Affiliation(s)
- Idan Lendner
- Pediatric Infectious Disease Unit, Soroka University Medical Center, Beer-Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Naphtali Justman
- Pediatric Infectious Disease Unit, Soroka University Medical Center, Beer-Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Noga Givon-Lavi
- Pediatric Infectious Disease Unit, Soroka University Medical Center, Beer-Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Michal S. Maimon
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Department of Pediatric Emergency Medicine, Soroka University Medical Center, Beer-Sheva, Israel
| | - Inbal Kestenbaum
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Department of Pediatric Emergency Medicine, Soroka University Medical Center, Beer-Sheva, Israel
| | - Shalom Ben-Shimol
- Pediatric Infectious Disease Unit, Soroka University Medical Center, Beer-Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Pain experienced by infants and toddlers at urine collection bag removal: A randomized, controlled, clinical trial. Int J Nurs Stud 2019; 95:1-6. [PMID: 30981953 DOI: 10.1016/j.ijnurstu.2019.03.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 03/18/2019] [Accepted: 03/18/2019] [Indexed: 01/21/2023]
Abstract
BACKGROUND In pre-continent children, collection bags are frequently used as a first-line option to obtain a urine specimen. This practice, acknowledged by several guidelines for the step of UTI screening, is driven by a perception of the technique as being more convenient and less painful. However, our own experience led us to consider bag removal as a painful experience. OBJECTIVE Our aim was to determine whether the use of an oleo-calcareous liniment to aid bag removal reduced the acute pain expressed by young children. METHODS This prospective, randomized, controlled, single blind study was carried out in two emergency pediatrics departments. Pre-continent children aged 0-36 months admitted with an indication for urine testing were eligible for the study. Urine for dipstick test screening was obtained using a collection bag. At micturition, the patients were randomized into bag removal with (intervention group) or without (control group) liniment. Bag removal was recorded on video in such a manner as to permit independent assessments of pain by two evaluators blinded to group allocation. Pain was assessed using the FLACC scale. FINDINGS 135 patients were analyzed: 70 in the intervention group and 65 in the control group. The median FLACC scores [interquartile range] for the intervention and control groups, respectively 4.0 [2.0-7.0] and 4.0 [3.0-7.0], did not differ significantly (p = 0.5). A FLACC score ≥4 was obtained for 56% of the patients and a score ≥7 for 28%. CONCLUSION Removal of urine collection bags caused moderate to severe pain in half of the children included. The use of an oleo-calcareous liniment did not reduce this induced pain.
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18
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McDaniel CE, Ralston S, Lucas B, Schroeder AR. Association of Diagnostic Criteria With Urinary Tract Infection Prevalence in Bronchiolitis: A Systematic Review and Meta-analysis. JAMA Pediatr 2019; 173:269-277. [PMID: 30688987 PMCID: PMC6439888 DOI: 10.1001/jamapediatrics.2018.5091] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Concomitant urinary tract infection (UTI) is a frequent concern in febrile infants with bronchiolitis, with a prior meta-analysis suggesting a prevalence of 3.3%. However, the definition of UTI in these studies has generally not incorporated urinalysis (UA) results. OBJECTIVE To conduct a systematic review and meta-analysis examining the prevalence of UTI in infants with bronchiolitis when positive UA results are incorporated into the UTI definition. DATA SOURCES Medline (1946-2017) and Ovid EMBASE (1976-2017) through August 2017 and bibliographies of retrieved articles. STUDY SELECTION Studies reporting UTI prevalence in bronchiolitis. DATA EXTRACTION Data were extracted in accordance with meta-analysis of observational studies in epidemiology guidelines via independent abstraction by multiple investigators. Random-effects models generated a weighted pooled event rate with corresponding 95% confidence intervals. MAIN OUTCOMES AND MEASURES Prevalence of UTI. RESULTS We screened 477 unique articles by abstract, with full-text review of 30 studies. Eighteen bronchiolitis studies reported a UTI prevalence and 7 of these reported UA data for inclusion in the meta-analysis. The overall reported prevalence of UTI in bronchiolitis from these 18 studies was 3.1% (95% CI, 1.8%-4.6%). With the addition of positive UA results (defined as the presence of pyuria or nitrites) as a diagnostic criterion, the prevalence of UTI as reported in the 7 studies in bronchiolitis was 0.8% (95% CI, 0.3%-1.4%). Sensitivity analyses yielded similar results, including for infants younger than 90 days. Heterogeneous definitions of UTI and UA criteria introduced uncertainty into prevalence estimates. CONCLUSIONS AND RELEVANCE When a positive UA result is added as a diagnostic criterion, the estimated prevalence of concomitant UTI is less than recommended testing thresholds for bronchiolitis.
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Affiliation(s)
- Corrie E. McDaniel
- Department of Pediatrics, Seattle Children’s Hospital, University of Washington, Seattle
| | - Shawn Ralston
- Department of Pediatrics, Children’s Hospital at Dartmouth-Hitchcock, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Brian Lucas
- The Dartmouth Institute for Health Policy and Clinical Practice and the Department of Medicine, Lebanon, New Hampshire
| | - Alan R. Schroeder
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
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Kasmire KE, Hoppa EC, Patel PP, Boch KN, Sacco T, Waynik IY. Reducing Invasive Care for Low-risk Febrile Infants Through Implementation of a Clinical Pathway. Pediatrics 2019; 143:peds.2018-1610. [PMID: 30728272 DOI: 10.1542/peds.2018-1610] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/29/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Significant variation in management of febrile infants exists both nationally and within our institution. Risk stratification can be used to identify low-risk infants who can be managed as outpatients without lumbar puncture (LP) or antibiotics. Our objective was to reduce invasive interventions for febrile infants aged 29 to 60 days at low risk for serious bacterial infection (SBI) through implementation of a clinical pathway supported by quality improvement (QI). METHODS The evidence-based clinical pathway was developed and implemented by a multidisciplinary team with continuous-process QI to sustain use. Low-risk infants who underwent LP, received antibiotics, and were admitted to the hospital were compared pre- and postpathway implementation with SBI in low-risk infants and appropriate care for high-risk infants as balancing measures. RESULTS Of 350 included patients, 220 were pre- and 130 were postpathway implementation. With pathway implementation in July 2016, invasive interventions decreased significantly in low-risk infants, with LPs decreasing from 32% to 0%, antibiotic administration from 30% to 1%, and hospital admission from 17% to 2%. Postimplementation, there were 0 SBIs in low-risk infants versus 29.2% in high-risk infants. The percentage of high-risk patients receiving care per pathway remained unchanged. Improvement was sustained for 12 months through QI interventions, including order-set development and e-mail reminders. CONCLUSIONS Implementation of a clinical pathway by using QI methods resulted in sustained reduction in invasive interventions for low-risk febrile infants without missed SBIs. Clinical pathways and QI can be key strategies in the delivery of evidence-based care for febrile infants.
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Affiliation(s)
- Kathryn E Kasmire
- Connecticut Children's Medical Center, Hartford, Connecticut; .,School of Medicine, University of Connecticut, Farmington, Connecticut; and.,Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Eric C Hoppa
- Connecticut Children's Medical Center, Hartford, Connecticut.,Department of Pediatrics
| | - Pooja P Patel
- School of Medicine, University of Connecticut, Farmington, Connecticut; and
| | - Kelsey N Boch
- School of Medicine, University of Connecticut, Farmington, Connecticut; and
| | - Tina Sacco
- Connecticut Children's Medical Center, Hartford, Connecticut
| | - Ilana Y Waynik
- Connecticut Children's Medical Center, Hartford, Connecticut.,Department of Pediatrics
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Kaufman J, Temple-Smith M, Sanci L. Urinary tract infections in children: an overview of diagnosis and management. BMJ Paediatr Open 2019; 3:e000487. [PMID: 31646191 PMCID: PMC6782125 DOI: 10.1136/bmjpo-2019-000487] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 09/10/2019] [Accepted: 09/12/2019] [Indexed: 01/05/2023] Open
Abstract
Urinary tract infections (UTIs) are a common and potentially serious bacterial infection of childhood. History and examination findings can be non-specific, so a urine sample is required to diagnose UTI. Sample collection in young precontinent children can be challenging. Bedside dipstick tests are useful for screening, but urine culture is required for diagnostic confirmation. Antibiotic therapy must be guided by local guidelines due to increasing antibiotic resistance. Duration of therapy and indications for imaging remain controversial topics and guidelines lack consensus. This article presents an overview of paediatric UTI diagnosis and management, with highlights of recent advances and evidence updates.
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Affiliation(s)
- Jonathan Kaufman
- Department of Paediatrics, Western Health, Sunshine Hospital, St Albans, Victoria, Australia.,Health Services Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of General Practice, Faculty of Medicine Dentistry & Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Meredith Temple-Smith
- Department of General Practice, Faculty of Medicine Dentistry & Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Lena Sanci
- Department of General Practice, Faculty of Medicine Dentistry & Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
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21
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Pantell RH, Roberts KB, Greenhow TL, Pantell MS. Advances in the Diagnosis and Management of Febrile Infants: Challenging Tradition. Adv Pediatr 2018; 65:173-208. [PMID: 30053923 DOI: 10.1016/j.yapd.2018.04.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Robert H Pantell
- Kapi'olani Medical Center for Women and Children, 1319 Punahou Street, Honolulu, HI 96824, USA.
| | | | - Tara L Greenhow
- Kaiser Permanente, Northern California, 2200 O'Farrell St, San Francisco, CA 94115, USA
| | - Matthew S Pantell
- University of California San Francisco, Suite 465, 3333 California Street, San Francisco, CA 94118, USA
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Shaikh N, Hoberman A, Hum SW, Alberty A, Muniz G, Kurs-Lasky M, Landsittel D, Shope T. Development and Validation of a Calculator for Estimating the Probability of Urinary Tract Infection in Young Febrile Children. JAMA Pediatr 2018; 172:550-556. [PMID: 29710324 PMCID: PMC6137527 DOI: 10.1001/jamapediatrics.2018.0217] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Accurately estimating the probability of urinary tract infection (UTI) in febrile preverbal children is necessary to appropriately target testing and treatment. OBJECTIVE To develop and test a calculator (UTICalc) that can first estimate the probability of UTI based on clinical variables and then update that probability based on laboratory results. DESIGN, SETTING, AND PARTICIPANTS Review of electronic medical records of febrile children aged 2 to 23 months who were brought to the emergency department of Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania. An independent training database comprising 1686 patients brought to the emergency department between January 1, 2007, and April 30, 2013, and a validation database of 384 patients were created. Five multivariable logistic regression models for predicting risk of UTI were trained and tested. The clinical model included only clinical variables; the remaining models incorporated laboratory results. Data analysis was performed between June 18, 2013, and January 12, 2018. EXPOSURES Documented temperature of 38°C or higher in children aged 2 months to less than 2 years. MAIN OUTCOMES AND MEASURES With the use of culture-confirmed UTI as the main outcome, cutoffs for high and low UTI risk were identified for each model. The resultant models were incorporated into a calculation tool, UTICalc, which was used to evaluate medical records. RESULTS A total of 2070 children were included in the study. The training database comprised 1686 children, of whom 1216 (72.1%) were female and 1167 (69.2%) white. The validation database comprised 384 children, of whom 291 (75.8%) were female and 200 (52.1%) white. Compared with the American Academy of Pediatrics algorithm, the clinical model in UTICalc reduced testing by 8.1% (95% CI, 4.2%-12.0%) and decreased the number of UTIs that were missed from 3 cases to none. Compared with empirically treating all children with a leukocyte esterase test result of 1+ or higher, the dipstick model in UTICalc would have reduced the number of treatment delays by 10.6% (95% CI, 0.9%-20.4%). CONCLUSIONS AND RELEVANCE UTICalc estimates the probability of UTI by evaluating the risk factors present in the individual child. As a result, testing and treatment can be tailored, thereby improving outcomes for children with UTI.
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Affiliation(s)
- Nader Shaikh
- Division of General Academic Pediatrics, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Alejandro Hoberman
- Division of General Academic Pediatrics, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Stephanie W. Hum
- Medical student, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Anastasia Alberty
- Division of General Academic Pediatrics, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Gysella Muniz
- Division of General Academic Pediatrics, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Marcia Kurs-Lasky
- Division of General Academic Pediatrics, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Douglas Landsittel
- Institute for Clinical Research Education, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Timothy Shope
- Division of General Academic Pediatrics, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Reaffirmation of AAP Clinical Practice Guideline: The Diagnosis and Management of the Initial Urinary Tract Infection in Febrile Infants and Young Children 2-24 Months of Age. Pediatrics 2016; 138:peds.2016-3026. [PMID: 27940735 DOI: 10.1542/peds.2016-3026] [Citation(s) in RCA: 164] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Affiliation(s)
- Kenneth B Roberts
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina; and Cone Health, Greensboro, North Carolina
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Commentary to "Determinants of practice patterns in pediatric UTI". J Pediatr Urol 2016; 12:309. [PMID: 27506308 DOI: 10.1016/j.jpurol.2016.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 06/15/2016] [Indexed: 11/20/2022]
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