Transcript Journal Club/May 30, 2003 Internet Based Interactive

Journal Club/July 31, 2009.
Dore-Bergeron et al. Urinary
tract infections in 1-3 month
old infants: ambulatory
treatment with intravenous
antibiotics
David H. Rubin, MD
Chairman and Program Director, Pediatrics
St Barnabas Hospital
Professor of Clinical Pediatrics, Albert Einstein College of
Medicine
OBJECTIVES OF
SEMINAR
Aim
Hypothesis
Methods and statistical
strategies
Conclusion
Competency based evaluation
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 BASED
OBJECTIVES

Medical Knowledge
• knowledge about the established and
evolving biomedical, clinical, and
cognate (epidemiological and socialbehavioral) sciences and their
application to patient care
COMPETENCY BASED
OBJECTIVES

Patient Care
• family centered patient care
developmentally and age appropriate
compassionate and effective for
treatment of health care problems
and promotion of health
COMPETENCY BASED
OBJECTIVES

Practice Based Learning
• investigation and evaluation of patient
care, and the assimilation of scientific
evidence

Communication Skills
• interpersonal and communication skills
resulting in effective information
exchange and learning with patients,
families and professional associates
COMPETENCY BASED
OBJECTIVES

System Based Practice
• understanding systems of health care
organization, financing, and delivery,
and the relationship of one’s local
practice and these larger systems

Professionalism
• carrying out professional
responsibilities, adherence to ethical
principles, and sensitivity to diverse
patient populations
INTRODUCTION

Usual practice is to hospitalize young
infants - especially those < 3 months of
age with urinary tract infections due to
• Risk of bacteremia and other SBI
• Risk of renal scarring


“Ambulatory treatment of UTI in the 3m-5
year group has been shown to be safe,
feasible and satisfactory to parents…”
No study of same topic to date in younger
age group
HYPOTHESIS/AIM OF
STUDY

Specific challenges (e.g. IV access)
and reluctance of ED physicians to
discharge home young infants with
bacterial infections during the first 2448 hours of treatment could be
addressed with successful OPD
treatment with IV antibiotics in a “day
treatment center” in infants 1-3
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

DISCUSSION




Ambulatory treatment of UTI for 30-90day old
infants with febrile UTI’s with short term IV
treatment is “feasible.”
“Treatment failures” (7/8) due to hospital admission;
patients usually admitted due to positive blood
cultures and were not clinically unstable
Need to complete VCUG and sonogram soon to rule
out potential pathology
Prior studies looking at oral antibiotics for febrile UTI
did not include younger population
DISCUSSION

Limitations
• ?Generalizability of findings
•
•
Location
Population of participants
• ?Long term followup
• How was the definition of “success” created?
• Attending physician had option to assign diagnosis
of UTI without any laboratory evidence
DISCUSSION

Strengths of the study
• Interesting question, important

Weaknesses of the study
• Population very different (generalizability
limited); impossible to perform in NYC
• Author excluded parents who were
“dubious”
COMPETENCY BASED
OBJECTIVES

Medical Knowledge
• knowledge about the established and
evolving biomedical, clinical, and
cognate (epidemiological and socialbehavioral) sciences and their
application to patient care
•
Treatment of febrile UTI in children
COMPETENCY BASED
OBJECTIVES

Patient Care
• family centered patient care
developmentally and age appropriate
compassionate and effective for
treatment of health care problems
and promotion of health
•
Parents may not understand issues
surrounding UTI’s
COMPETENCY BASED
OBJECTIVES

Practice Based Learning
• investigation and evaluation of patient care,
and the assimilation of scientific evidence
•

Scientific evaluation of hypothesis, methods, and
conclusion of article
Communication Skills
• interpersonal and communication skills
resulting in effective information exchange
and learning with patients, families and
professional associates
•
Parental education and support critical
COMPETENCY BASED
OBJECTIVES

System Based Practice
• understanding systems of health care
organization, financing, and delivery, and
the relationship of one’s local practice and
these larger systems
•

Who gets admitted and who will pay for this?
Admission warranted on medical reasons?
Professionalism
• carrying out professional responsibilities,
adherence to ethical principles, and
sensitivity to diverse patient populations
•
Patient education in diverse cultures