Emergency Department Revisits After an Initial Parenteral Antibiotic Dose for UTI

Defining complicated urinary tract infection and route of antibiotics in children presenting to the emergency department: a cohort study using the Melbourne RUPERT clinical score

OBJECTIVES

Most children with uncomplicated urinary tract infections (UTI) can be managed with oral antibiotics. However, identifying those likely to fail oral and need intravenous antibiotics due to complicating features at presentation is challenging. We aimed to derive, validate and test a score to guide initial antibiotic route.

DESIGN

This cohort study enrolled children both prospectively and retrospectively. Patients were divided into two groups based on whether they received intravenous or oral antibiotics after 24 hours, including those who switched between routes. Children diagnosed with confirmed UTI were used to derive then validate the score, comparing complicating clinical features between the two groups. Combinations of significantly differentiating features generated receiver operating characteristic curves and the optimal cut-off for intravenous antibiotic use was selected.

SETTING

The emergency department of a tertiary paediatric hospital.

PARTICIPANTS

All children aged 3 months-17 years with suspected UTI were eligible, and were included if they fulfilled the diagnostic criteria for UTI.

OUTCOME MEASURES

The effectiveness of the derived clinical score to differentiate patients at presentation who had complicated UTI requiring ongoing intravenous antibiotics.

RESULTS

There were 1240 patients, of whom 167 children aged 12 months-11 years with confirmed UTI comprised the derivation cohort. The combination of features that performed optimally (area under curve 0.85, 95% CI 0.79 to 0.91) were: rigors, urological abnormality, fever (≥38°C), emesis, recurrent (≥3) UTI, tachycardia: the RUPERT score (1 point each, maximum 6). A score ≥3 accurately classified route of antibiotics after 24 hours for 80% patients (sensitivity 77%, specificity 81%). For the 168 patients in the validation cohort, the score accurately classified 76% (sensitivity 67%, specificity 78%). The score tested well in 'probable' UTI and adolescents, and less well in infants.

CONCLUSION

The Melbourne RUPERT score provides the first standardised, easy-to-use score to aid clinicians in deciding route of antibiotics for more complicated UTI in children. It now needs prospective validation.

Therapies in preclinical and in early clinical development for the treatment of urinary tract infections: from pathogens to therapies

INTRODUCTION

Urinary tract infections (UTIs) are a prevalent health challenge characterized by the invasion and multiplication of microorganisms in the urinary system. The continuous exploration of novel therapeutic interventions is imperative. Advances in research offer hope for revolutionizing the management of UTIs and improving the overall health outcomes for individuals affected by these infections.

AREAS COVERED

This review aimed to provide an overview of existing treatments for UTIs, highlighting their strengths and limitations. Moreover, we explored and analyzed the latest therapeutic modalities under clinical development. Finally, the review offered a picture into the potential implications of these therapies on the future landscape of UTIs treatment, discussing possible advancements and challenges for further research.

EXPERT OPINION

Comprehensions into the pathogenesis of UTIs have been gleaned from foundational basic science studies, laying the groundwork for the exploration of novel therapeutic interventions. The primary source of evidence originates predominantly from animal studies conducted on murine models. Nevertheless, the lack of clinical trials interferes the acquisition of robust evidence in humans. The challenges presented by the heterogeneity and virulence of uropathogens add an additional layer of complexity, posing an obstacle that scientists and clinicians are actively grappling with in their pursuit of effective solutions.

National Survey on the Emergency Department Management of Febrile Infants 29 to 60 Days Old With an Abnormal Urinalysis

OBJECTIVES

Recent clinical practice guidelines recommend that decisions regarding lumbar puncture (LP) for febrile infants older than 28 days should no longer be based on urinalysis results, but rather independently determined by inflammatory markers and sometimes guided by shared decision-making (SDM). This study sought to assess management decisions for febrile infants aged 29 to 60 days with an abnormal urinalysis.

METHODS

A scenario-based survey was sent to emergency department physicians at all 15 Canadian tertiary pediatric centers. Participants were asked questions regarding management decisions when presented with a well-appearing febrile infant in the second month of life with either an abnormal or normal urinalysis.

RESULTS

Response rate was 50.2% (n = 116/231). Overall, few respondents would perform an LP based on either an abnormal or normal urinalysis alone (10.3% and 6.0%, respectively). However, regression analysis demonstrated that decisions regarding LP were influenced by urinalysis results ( P < 0.001), with respondents more likely to defer to inflammatory marker results for infants with a normal urinalysis result (57.8%) compared with those with an abnormal urinalysis (28.4%). Hospitalization (62.1%) and empiric antibiotic treatment by intravenous route (87.9%) were both frequent for low-risk infants with an abnormal urinalysis. Nearly half of respondents reported rarely (<25% of encounters) engaging families in SDM regarding LP decisions.

CONCLUSIONS

Knowledge translation initiatives reflecting current evidence should target use of inflammatory markers rather than urinalysis results to guide decisions regarding LP. Efforts emphasizing outpatient management with oral antibiotics and SDM for low-risk infants with an abnormal urinalysis could also further align management with current evidence and guidelines.

Association between antibiotic administration before discharge and emergency department length of stay for urinary tract infection: A retrospective analysis

BACKGROUND

Patients with urinary tract infections (UTIs) may have treatment initiated in the emergency department (ED) before discharge with an antibiotic prescription. The effect of a single antibiotic dose administered before discharge on ED length of stay (LOS) is unknown.

OBJECTIVES

The purpose of this study was to compare the LOS and the rate of revisits within 30 days among patients diagnosed as having UTIs other than pyelonephritis who received parenteral, oral, or no antibiotic during an ED visit.

METHODS

This was a retrospective cohort study of adult patients with a diagnosis of UTI who received an antibiotic prescription at discharge from a single community ED in the United States between 2019 and 2020. Patients were excluded if they were admitted to the hospital, were diagnosed as having pyelonephritis, or had an ED visit in the previous 30 days. ED LOS was compared using 3-factor analysis of variance. ED revisits at 72 hours and 30 days were compared using the chi-square test.

RESULTS

A total of 694 patients with an ED visit for UTI and an antibiotic prescription at discharge were included. The mean age of the study population was 58 years. Parenteral antibiotic administration in the ED was associated with a 60-minute increase in ED LOS compared with those who received an oral antibiotic (P < 0.001) and a 30-minute increase in ED LOS compared with no antibiotic (P < 0.001). No differences were observed in revisits to the ED at 72 hours (5%, 5%, 2%; P = 0.17) or 30 days (15%, 16%, 17%: P = 0.98) among patients who received parenteral, oral, or no antibiotic before discharge.

CONCLUSIONS

A single dose of parenteral antibiotic before discharge was associated with an increased ED LOS compared with treatment with oral antibiotic or discharge without ED treatment. ED revisit rates were similar regardless of ED treatment.

Outcomes for Patients with Urinary Tract Infection After an Initial Intravenous Antibiotics Dose Before Emergency Department Discharge

INTRODUCTION

To investigate the effect of single-dose intravenous antibiotics before emergency department (ED) discharge on the outcomes of patients with urinary tract infections (UTIs).

METHODS

This is a retrospective study conducted at the EDs of three medical centers. Patients aged over 18 years who presented to the ED with UTI and were discharged without admission between January 1, 2016 and December 31, 2017 were evaluated. The study group received a single dose of effective intravenous antibiotics on the basis of urine culture during the index ED visit following oral antibiotics, while the comparison group received oral antibiotics only. The primary outcomes were ED revisit within 72 h and admission following the return visit.

RESULTS

A total of 8168 patients were included. Of these, 20.9% received intravenous antibiotics before ED discharge. Patients who received effective intravenous antibiotics before ED discharge were associated with less than 72-h ED revisit (adjusted odds ratio [OR] 0.791, 95% confidence interval [CI] 0.640-0.979]), but not decreased admission following the return visit (adjusted OR 0.921, 95% CI [0.731-1.153]). In subgroup analysis, parenteral antibiotic use during the index ED visit was associated with decreased admission following ED revisit in patients who presented with fever (adjusted OR 0.605; 95% CI 0.443-0.932).

CONCLUSION

For patients with UTI and clinically well to be discharged from the ED, a single dose of effective intravenous antibiotics before ED discharge was associated with decreased 72-h ED revisit. In patients with febrile UTI, initial intravenous antibiotics were associated with decreased revisit leading to admissions.

Parenteral Antibiotic Use Among Ambulatory Children in United States Children's Hospital Emergency Departments

Background

Despite increasing recognition of the importance of optimal antibiotic selection and expansion of antimicrobial stewardship activities to ambulatory settings, few studies have examined the frequency of parenteral antibiotic use among ambulatory children. We assessed the prevalence and patterns of parenteral antibiotic administration among ambulatory children in pediatric emergency departments (EDs).

Methods

We conducted a cross-sectional assessment of parenteral antibiotic use among ambulatory children aged 0–18 years in 49 US children’s hospital EDs in 2018. We assessed the prevalence rates of parenteral antibiotic use and stratified these by patient-, clinic-, and hospital-level characteristics. We also assessed the prevalence of use of specific antibiotics by age and diagnosis category. Among encounters associated with an infection diagnosis, we identified factors associated with parenteral antibiotic use using multivariable logistic regression.

Results

Among 3452011 ambulatory ED encounters in 2018, parenteral antibiotics were administered in 62648 (1.8%). The highest proportion of parenteral antibiotic use occurred in the 15–18-year age group (3.3%) and among encounters in children with complex chronic conditions (8.9%) and with primary diagnoses of neoplasms (36%). Ceftriaxone was the most commonly administered parenteral antibiotic (61%). In multivariable analysis, several factors including age ≤2 months, White race, private insurance, complex chronic conditions, digestive and genitourinary system diseases, and encounters attributed to emergency medicine providers were significantly associated with higher odds of parenteral antibiotic use.

Conclusions

This study demonstrates substantial variability in the frequency of parenteral antibiotic administration by age and diagnosis in the ambulatory ED setting and highlights potential opportunities to target stewardship activities.

Oral or intravenous antibiotics?

Intravenous antibiotics are overused in hospitals. Many infections can be managed with oral antibiotics

Oral antibiotics avoid the adverse effects of intravenous administration. They are also usually less expensive

When intravenous antibiotics are indicated, it may be possible to switch to oral therapy after a short course. There are guidelines to aid the clinician with the timing of the switch so that there is no loss of efficacy

Infections that may be suitable for a short course of intravenous antibiotic include pneumonia, complicated urinary tract infections, certain intra-abdominal infections, Gram-negative bacteraemia, acute exacerbations of chronic lung disease, and skin and soft tissue infections

Bone and joint infections and infective endocarditis are managed with prolonged courses of intravenous antibiotics. However, there is research looking at the feasibility of an earlier switch to oral antibiotics in these conditions