Stop taking the piss

Luke BurmanSTOPPIT

Queensland Autumn Symposium May 2015

18mo boy fevers 1/7

No significant history otherwise

Vaccinations UTD

18mo boy fevers 1/7

No significant history otherwise

Vaccinations UTD

18mo boy fevers 1/7T39.1RR20HR100SpO2

98%CRT <2Alert

No significant history otherwise

Vaccinations UTD

18mo boy fevers 1/7T39.1RR20HR100SpO2

98%CRT <2Alert

Looks very well, smiling, iPhone+

No significant history otherwise

Vaccinations UTD

18mo boy fevers 1/7T39.1RR20HR100SpO2

98%CRT <2Alert

Looks very well, smiling, iPhone+

Neither focus nor concern on detailed systems exam

No significant history otherwise

Vaccinations UTD

18mo boy fevers 1/7T39.1RR20HR100SpO2

98%CRT <2Alert

Looks very well, smiling, iPhone+

Neither focus nor concern on detailed systems exam

Past his bed timeGrumpy

pa(re)nts

No significant history otherwise

Vaccinations UTD

18mo boy fevers 1/7T39.1RR20HR100SpO2

98%CRT <2Alert

Looks very well, smiling, iPhone+

Neither focus nor concern on detailed systems exam

Past his bed timeGrumpy

pa(re)nts

He’s been in ED 35mins

No significant history otherwise

Vaccinations UTD

18mo boy fevers 1/7T39.1RR20HR100SpO2

98%CRT <2Alert

Looks very well, smiling, iPhone+

Neither focus nor concern on detailed systems exam

Past his bed timeGrumpy

pa(re)nts

He’s been in ED 35mins

What do you do next?

24

Well FWS 2-24mo

Well FWS 2-24moOptions

Well FWS 2-24moOptionsA. Keep in ED until clean catch urine

(CCU) and discharge on ABs if urine dip positive

Well FWS 2-24moOptionsA. Keep in ED until clean catch urine

(CCU) and discharge on ABs if urine dip positive

B. Keep in ED until CCU and then longer if CCU is positive on dip, discharge on ABs if MCS positive

Well FWS 2-24moOptionsA. Keep in ED until clean catch urine

(CCU) and discharge on ABs if urine dip positive

B. Keep in ED until CCU and then longer if CCU is positive on dip, discharge on ABs if MCS positive

C. Discharge now, no further work-up

Well FWS 2-24moOptionsA. Keep in ED until clean catch urine

(CCU) and discharge on ABs if urine dip positive

B. Keep in ED until CCU and then longer if CCU is positive on dip, discharge on ABs if MCS positive

C. Discharge now, no further work-upD. Discharge now, some other

approach

So why do we take the piss…?

So why do we take the piss…?

? Because we always do? Because guidelines say so

So why do we take the piss…?

? Because we always do? Because guidelines say so? To identify UTI…..so that

we can treat it!!

So why do we take the piss…?

? Because we always do? Because guidelines say so? To identify UTI…..so that

we can treat it!!? To prevent pyelonephritis

So why do we take the piss…?

? Because we always do? Because guidelines say so? To identify UTI…..so that

we can treat it!!? To prevent pyelonephritis? To prevent renal scarring

So why do we take the piss…?

? Because we always do? Because guidelines say so? To identify UTI…..so that

we can treat it!!? To prevent pyelonephritis? To prevent renal scarring? To prevent urosepsis and DEATH

So why do we take the piss…?

? Because we always do? Because guidelines say so? To identify UTI…..so that

we can treat it!!? To prevent pyelonephritis? To prevent renal scarring? To prevent urosepsis and DEATH? To prevent CKD and hypertension

So why do we take the piss…?

? Because we always do? Because guidelines say so? To identify UTI…..so that

we can treat it!!? To prevent pyelonephritis? To prevent renal scarring? To prevent urosepsis and DEATH? To prevent CKD and hypertension? To decrease symptoms

Anals of Emergency Medicine

n

UTI in kids – big deal?

UTI in kids – big deal?8% of girls and 2% of boys are diagnosed with at

least one UTI by the age of seven years.

UTI in kids – big deal?8% of girls and 2% of boys are diagnosed with at

least one UTI by the age of seven years.= a “thing”

UTI in kids – big deal?8% of girls and 2% of boys are diagnosed with at

least one UTI by the age of seven years.

Incidence in febrile children<3mo

girl 7.5% boy 8.7%

3-12mo girl 8.3% boy 1.7%

12-24 mo girl 2.1% boys????

UTI in kids – big deal?8% of girls and 2% of boys are diagnosed with at

least one UTI by the age of seven years.

Incidence in febrile children<3mo

girl 7.5% boy 8.7%

3-12mo girl 8.3% boy 1.7%

12-24 mo girl 2.1% boys???? Shaikh N, Morone NE, Bost JE, et al. Prevalence of urinary tract infection in childhood: a meta-analysis. Pediatr Infect Dis J. 2008;27:302-308.

Will this well child get septic?

Will this well child get septic?

and

DIE!!!

Will this well child get septic?

How common is paediatric urosepsis?

and

DIE!!!

Will this well child get septic?

How common is paediatric urosepsis?

Older children and teens (<19yo): 0.56/1000/year

<28d: 3.6/1000/year

70% of uroseptics were neonatal

and

DIE!!!

Will this well child get septic?

Evidence that paediatric urosepsis, especially outside neonatal age is RARE

and

DIE!!!

Will this well child get septic?

Evidence that paediatric urosepsis, especially outside neonatal age is RARE

60% due to bacteraemia and respiratory causes

and

DIE!!!

Will this well child get septic?

Evidence that paediatric urosepsis, especially outside neonatal age is RARE

60% due to bacteraemia and respiratory causes

Evidence that paediatric urosepsis is LESS FATAL than sepsis from other sources

and

DIE!!!

Will this well child get septic?

Evidence that paediatric urosepsis, especially outside neonatal age is RARE

60% due to bacteraemia and respiratory causes

Evidence that paediatric urosepsis is LESS FATAL than sepsis from other sources

Case fatality rate of 3.7% v.~10%

and

DIE!!!

Will this well child get septic?

Evidence that paediatric urosepsis, especially outside neonatal age is RARE

60% due to bacteraemia and respiratory causes

Evidence that paediatric urosepsis is LESS FATAL than sepsis from other sources

Case fatality rate of 3.7% v.~10%

Not just a modern finding. Developed world and work-up from pre-1970s papers do not identify a higher rate of urosepsis in the absence of advanced medicine

and

DIE!!!

Will this well child get septic?

No evidence about rate of progression of simple UTI to sepsis and nothing in historical literature to suspect that this rate would be high.

and

DIE!!!

Will this well child get septic?

No evidence about rate of progression of simple UTI to sepsis and nothing in historical literature to suspect that this rate would be high.

Paediatric UTI frequently presents as a prolonged fever >2/7 without other localizing symptoms

and

DIE!!!

Will this well child get septic?

No evidence about rate of progression of simple UTI to sepsis and nothing in historical literature to suspect that this rate would be high.

Paediatric UTI frequently presents as a prolonged fever >2/7 without other localizing symptoms

Late presentation is not clearly associated with sepsis

and

DIE!!!

Will this well child get septic?

Paediatric urosepsis is:

Rare

Not particularly fatal

Unlikely to rapidly progress from uncomplicated UTI

and

DIE!!!

Will this well child get septic?

Probably not…

and

DIE!!!

Phew, but what about scarring ?

Phew, but what about scarring ?

? Does UTI progress to pyelonephritis

? Does UTI progress to scarring

Phew, but what about scarring ?

? Does UTI progress to pyelonephritis47%

? Does UTI progress to scarring15%

Phew, but what about scarring ?

? Does UTI progress to pyelonephritis47%

? Does UTI progress to scarring15%

Yes&

Yes

DONE!Causes

scarring: test and

treat

Hang on…is scarring bad?

Hang on…is scarring bad?

Old guidelines based on 2 studiesGill et al. 1976. Chart Review. N=100 children with hypertension. Reflux nephropathy believed to be the cause in 14. No long-term follow up.

Shore and Gorelick 1999. A review of several very small studies. Many were of children with abN IVU. Suggestion of decreased GFR

Hang on…is scarring bad?

Multiple other studies since 2000Prospective, controlled, largeLong-term follow-upConfirm rate of scarring with paediatric UTINo clinically or statistically significant increased rate of CKD or decreased GFREpidemiological data also

Hang on…is scarring bad?

Scarring sounds bad…

But we got the BOMB!

Do antibiotics even work?

UTIPyelonephritisScarringSepsisSymptoms

Do antibiotics even work?

UTIPyelonephritisScarringSepsisSymptoms

Do antibiotics even work?

UTIPyelonephritisScarringSepsisSymptoms

Natural HistoryNo good data!!!!?1908 German study – can’t find it!

Do antibiotics even work?

UTIPyelonephritisScarringSepsisSymptoms

Natural HistoryUnpublished prospective cohort study

presented at 2000 Pediatric Academic Societies Annual Meeting.n= 3066 infants 0-3mo T 38°Cmanaged per physicians whimsome investigated, sent home, some admitted, some treated

Statistical trickery~54 UTIs never received treatment2 infants subsequently diagnosed UTI Neither bacteremic; both treated and recovered uneventfully.

Do antibiotics even work?

UTI (?)PyelonephritisScarringSepsisSymptoms

Do antibiotics even work?

UTI (?)PyelonephritisScarringSepsisSymptoms

Do antibiotics even work?

UTI (?)PyelonephritisScarringSepsisSymptoms

Lots of recent studies including a Cochrane review of IV v PO

No data on whether ABs modify progression to pyelonephritis

Do antibiotics even work?

UTI (?)Pyelonephritis (?)ScarringSepsisSymptoms

Do antibiotics even work?

UTI (?)Pyelonephritis (?)ScarringSepsisSymptoms

Do antibiotics even work?AAP guidelines:Cites a chart review and a

retrospective study suggest early ABs decrease scarring

Several other retrospective audits also suggest reduced scarring, especially with early antibiotics

UTI (?)Pyelonephritis (?)ScarringSepsisSymptoms

Do antibiotics even work?AAP guidelines:Cites a chart review and a

retrospective study suggest early ABs decrease scarring

Several other retrospective audits also suggest reduced scarring, especially with early antibiotics

Recent prospective studies: several, good sized studies. Nearly all: no relation between timing of ABs and scarring. Only 1 study showed +ve association if ABs delayed >4.5 daysLatest: 287 children. No difference between early (<12h) AB

and delayed (up to 5h) AB groups

UTI (?)Pyelonephritis (?)ScarringSepsisSymptoms

Do antibiotics even work?

UTI (?)Pyelonephritis (?)Scarring (-)SepsisSymptoms

Do antibiotics even work?

UTI (?)Pyelonephritis (?)Scarring (-)SepsisSymptoms

Do antibiotics even work?

UTI (?)Pyelonephritis (?)Scarring (-)SepsisSymptoms

PreventionUrosepsis rare in kidsAntibiotic complications common

Do antibiotics even work?

UTI (?)Pyelonephritis (?)Scarring (-)SepsisSymptoms

PreventionUrosepsis rare in kidsAntibiotic complications common

Treatment

Do antibiotics even work?

UTI (?)Pyelonephritis (?)Scarring (-)Sepsis (+/-)Symptoms

Do antibiotics even work?

UTI (?)Pyelonephritis (?)Scarring (-)Sepsis (+/-)Symptoms

Do antibiotics even work?

UTI (?)Pyelonephritis (?)Scarring (-)Sepsis (+/-)Symptoms

Surpise! No data.

Do antibiotics even work?

UTI (?)Pyelonephritis (?)Scarring (-)Sepsis (+/-)Symptoms (?)

What?! No bug killers?

What?! No bug killers?

Otitis mediaTonsillitisPharyngitisSinusitisDrained abscessValvulopathy & dental proceduresOther minor infectionOther minor infection

First do no harm…

AnaphylaxisAntibiotic associated diarrhoeaPseudomembranous colitisDrug eruptionsAntimicrobial resistance

First do no harm…

AnaphylaxisAntibiotic associated diarrhoeaPseudomembranous colitisDrug eruptionsAntimicrobial resistance

MEDICALISATION OF MILD ILLNESS

PPV is important too…

Test Sn% (Range) Sp% (Range)

Leukocyte esterase test 83 (67-94) 78 (64-92)

Nitrite test 53(15-82) 98 (90-100)

Either leuocyte esterase of nitrites

93 (90-100) 72 (58-91)

Microscopy (WCC) 73 (32-100) 81 (45-98)

Microscopy (Bacteria) 81 (16-99) 83 (11-100)

Any one of above 99.8 (99-100) 70 (60-92)

PPV is important too…

+ PPV = 58%

PPV is important too…

+ =

PPV is important too…

Sterile pyuria: common

Asymptomatic bacteruria– VARIABLE BETWEEN 0.5 AND 4% BOYS <<<<<girls– Usually cited as 2%

So, what’re you saying?

So, what’re you saying?

Stop giving antibiotics to kids with UTI????????

So, what’re you saying?

Stop giving antibiotics to kids with UTI????????

Stop getting urine samples when UTI suspected???????

So, what’re you saying?

Stop giving antibiotics to kids with UTI????????

Stop getting urine samples when UTI suspected???????

NO

What I am saying

What I am saying

The evidence is such that the role of antibiotics in uncomplicated paediatric UTI should be questioned with good quality RCTs. Until

then, antibiotics for all paediatric UTI remain a standard of care.

What I am saying

The evidence is such that the role of antibiotics in uncomplicated paediatric UTI should be questioned with good quality RCTs. Until

then, antibiotics for all paediatric UTI remain a standard of care.

The evidence is such that aggressive policies demanding same day urinary collection in low risk, well infants and small children with FWS, outside the neonatal period, have no basis in

evidence and can be ignored.

What I am saying

The evidence is such that the role of antibiotics in uncomplicated paediatric UTI should be questioned with good quality RCTs. Until

then, antibiotics for all paediatric UTI remain a standard of care.

The evidence is such that aggressive policies demanding same day urinary collection in low risk, well infants and small children with FWS, outside the neonatal period, have no basis in

evidence and can be ignored.STOPPIT

What I am saying

The evidence is such that the role of antibiotics in uncomplicated paediatric UTI should be questioned with good quality RCTs. Until

then, antibiotics for all paediatric UTI remain a standard of care.

The evidence is such that aggressive policies demanding same day urinary collection in low risk, well infants and small children with FWS, outside the neonatal period, have no basis in

evidence and can be ignored.STOPPITKEEP ITFOR

NOW

4 weeks old + fever

12mo 3x UTIs FWS

Documented VUR

16mo multiple congenital abnormalities

CRT 4s

Looks unwell

Acquired immunodeficiency

On chemo

2mo – 2 yearsFever < 4 daysFWS on detailed surveyWell by senior opinionMinimal SxNo PHx UTINo risk factorsLives within cooeeAccess to follow upCapable parents

STO

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STO

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LET THEM GO HOMEHome clean catchStore in fridge >4hClear TCB adviceOpen door policyEnsure follow up

2mo – 2 yearsFever < 4 daysFWS on detailed surveyWell by senior opinionMinimal SxNo PHx UTINo risk factorsLives within cooeeAccess to follow upCapable parents