Vol. 191, No. 4S, Supplement, Sunday, May 18, 2014 THE JOURNAL OF UROLOGY� e443

Pediatrics: Urinary Tract Infection & VesicoureteralRelux

Moderated Poster

Sunday, May 18, 2014 3:30 PM-5:30 PM

MP44-01A COMPARISON OF PRACTICE PATTERNS IN THE MANAGEMENTOF VESICOURETERAL REFLUX BETWEEN PEDIATRICUROLOGISTS AND PEDIATRIC NEPHROLOGISTS

Cynthia D’Alessandri-Silva, Hartford/Farmington, CT; Katherine Herbst,Renee Silvis, Hartford, CT; Kristen Scarpato, Farmington, CT;Fernando Ferrer, John Makari*, Hartford/Farmington, CT

INTRODUCTION AND OBJECTIVES: Vesicoureteral reflux(VUR) is often diagnosed and managed by both Pediatric Urologists(PU) and Pediatric Nephrologists (PN), yet little data exists comparingpractice patterns between these two subspecialties. We sought todescribe practice variation between PU and PN as it pertains to VUR.

METHODS: An e-mail invitation was sent to 675 SPU and 753ASPN members. Survey Monkey was used to obtain demographic andpractice pattern data for commonly encountered clinical scenariosrelating to VUR and urinary tract infection (UTI). Data from non-PU/PNresponders and from those answering fewer than 37 of the 39 questions(95%) was excluded from analysis. Statistical analysis was performedusing SPSS 17.0. Categorical variables were compared using Chi-square test or Fisher’s Exact Test. Pair-wise comparisons were madeusing the Bonferroni adjustment.

RESULTS: 255 (18%) physicians responded; of these, 4 (2%)were non-PU/PN and 48 (19%) answered � 95% of survey questions,resulting in a final cohort of 203 respondents (133 PU, 70 PN). Age andpractice setting were similar; more non-US PU than PN responded to thesurvey (20% vs. 7%, P<0.05). 98% of PU and 83% of PN responded thatthey would evaluate a child with a single febrile UTI with imaging(p<0.001). 91% of PU and 99% of PN would evaluate a child with amultiple afebrile UTIs with imaging (p<0.001). Independent of the type ofUTI, PU favor using KUB and DMSA more frequently than PN, whereasPN prefer renal sonogram or VCUG. 78% and 74% of PU were some-what/very likely to consider deflux or reimplant for breakthrough infection,versus 60% and 28% of PN (p<0.05). 91% of PU vs. 76% of PN believethat treating bowel and bladder dysfunction (BBD) alone may lead toresolution of VUR (p<0.01). BBD screening by PU (58%) involved historyand other modalities; PN rely most often on history alone (60%). 58% ofurologists are somewhat/very likely to screen siblings with sonogramversus 40% of nephrologists (p<0.01). PU and PN were equally con-cerned with the emergence of resistant bacterial organisms when makingdecisions regarding prophylactic antibiotics (PN 72% vs. PU 69%).

CONCLUSIONS: Minimal consensus exists between PU andPN in the diagnosis and management of VUR. PU use more diverseimaging in diagnosis and are more likely to pursue surgical interventionfor breakthrough UTIs than PN. More aggressive evaluation for BBD byPU than PN may be related to belief in the impact BBD on VUR reso-lution. Further investigation is necessary to determine if practice vari-ation is related to training, society guidelines, or other factors.

Source of Funding: none

MP44-02A COMPARISON OF MANAGEMENT STRATEGIES FOROUTPATIENT PEDIATRIC URINARY TRACT INFECTIONS

Kara Saperston*, San Francisco, CA; Janet Hanley, Christopher Saigal,Los Angeles, CA; Hillary Copp, San Francisco, CA

INTRODUCTION AND OBJECTIVES: Current practice guide-lines for pediatric urinary tract infection (UTI) recommend urinalysis and

culture prior to the initiation of antibiotic therapy. No studies directlycompare the effectiveness of outpatient pediatric UTI treatment with andwithout urine culture use. Our goal is to compare four principal man-agement strategies for children with UTI: 1. Broad-spectrum antibiotictherapy with culture, 2. Broad-spectrum antibiotic therapy without cul-ture, 3. Narrow-spectrum antibiotic therapy with culture, and 4. Narrow-spectrum antibiotic therapy without culture.

METHODS: We used the Truven Health MarketScanA� Da-tabases, which contain healthcare claims information from employers,health plans, and hospitals from 2002-2010. We compared treatmentstrategies for outpatient UTI management in all children <18yrs with thediagnosis of UTI or pyelonephritis. We excluded children with complexurologic comorbidities and those admitted within the first 2 calendardays of presentation. We assumed all UTIs were cured over a 21-dayperiod of follow up. Outcomes were expressed in US dollars andadjusted using a medical price index model for inflation. We used alinear regression model to define net reduction in cost comparing thedifferent strategies. T-tests were used to compare the mean valuesbetween the groups.

RESULTS: Among 242,819 outpatient UTI episodes, 81,267were treated with broad-spectrum antibiotics and 161,552 were treatedwith narrow-spectrum antibiotics. Urine testing was performed in 73% ofUTI episodes. There was no difference in urine testing between broad-and narrow-spectrum treated UTIs. Lower rates of hospital admissionwere observed in the narrow-spectrum group with urine testingcompared with the broad-spectrum group without urine testing(p¼0.00001). The least costly management strategy was narrow-spectrum treatment with urine testing. Linear regression analysis oftreatment costs revealed empiric narrow-spectrum antibiotics with urinetesting is a more cost effective option than narrow-spectrum antibioticswithout urine testing, $477 vs. $796. Similarly, urine testing with empiricbroad-spectrum treatment is more cost effective than not obtaining urinetesting, $813 vs. $1167.

CONCLUSIONS: Urine testing is associated with lower treat-ment costs for both broad- and narrow- spectrum antibiotic prescriptionfor outpatient pediatric UTI. Empiric narrow-spectrum antibiotic treat-ment with urine testing is the most effective outpatient managementstrategy for UTI in children.

Source of Funding: This study was made possible by a grantthrough the Urologic Diseases in America (UDA) Project, whichis sponsored by the National Institute of Diabetes and Digestiveand Kidney Diseases (NIDDK), part of the National Institutes ofHealth.

MP44-03EARLY EFFECT OF AMERICAN ACADEMY OF PEDIATRICS UTIGUIDELINES ON EMERGENCY ADMISSIONS, RADIOGRAPHICIMAGING AND DIAGNOSIS OF VESICOURETERAL REFLUX

Laura S. Merriman, Angela M. Arlen*, Jared M. Kirsch, Hal C. Scherz,Edwin A. Smith, Bruce H. Broecker, Andrew J. Kirsch, Atlanta, GA

INTRODUCTION AND OBJECTIVES: In August of 2011, theAmerican Academy of Pediatrics revised their practice parameters fordiagnosis and management of febrile urinary tract infection (fUTI) inchildren two months to two years of age. Changes in imaging recom-mendations invigorated an ongoing debate regarding diagnosis andmanagement of vesicoureteral reflux (VUR) in young children. Wecompared the evaluation of young children with febrile UTI before andafter implementation of these guidelines.

METHODS: Two cohorts of children, aged 2 months to 2years, were assessed in the emergency department setting over twoseparate six-month periods e from January to June 2011 and Januaryto June 2012 e to evaluate effect of the guidelines. Patient de-mographics, fever, urine culture, renal/bladder ultrasound, voidingcystourethrogram (VCUG) and admission status were assessed.Children with previous history of VUR or VCUG, prior febrile UTI,undocumented urine culture or afebrile UTI (defined as temperature<101.5 � F) were excluded.