Stop taking the piss
Luke Burman
STOPPIT
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 1/7
T39.1
RR20
HR100
SpO2 98%
CRT <2
Alert
No significant
history otherwise
Vaccinations UTD
Looks very well,
smiling, iPhone+
18mo boy fevers 1/7
T39.1
RR20
HR100
SpO2 98%
CRT <2
Alert
No significant
history otherwise
Vaccinations UTD
Looks very well,
smiling, iPhone+
18mo boy fevers 1/7
T39.1
RR20
HR100
SpO2 98%
CRT <2
Alert
Neither focus nor
concern on
detailed systems
exam
No significant
history otherwise
Vaccinations UTD
Looks very well,
smiling, iPhone+
Past his bed time
Grumpy pa(re)nts
18mo boy fevers 1/7
T39.1
RR20
HR100
SpO2 98%
CRT <2
Alert
Neither focus nor
concern on
detailed systems
exam
No significant
history otherwise
Vaccinations UTD
Looks very well,
smiling, iPhone+
Past his bed time
Grumpy pa(re)nts
18mo boy fevers 1/7
T39.1
RR20
HR100
SpO2 98%
CRT <2
Alert
Neither focus nor
concern on
detailed systems
exam
He’s been in ED
35mins
No significant
history otherwise
Vaccinations UTD
Looks very well,
smiling, iPhone+
Past his bed time
Grumpy pa(re)nts
18mo boy fevers 1/7
T39.1
RR20
HR100
SpO2 98%
CRT <2
Alert
Neither focus nor
concern on
detailed systems
exam
He’s been in ED
35mins
What do you do next?
Well FWS 2-24mo
Well FWS 2-24mo
Options
Well FWS 2-24mo
Options
A. Keep in ED until clean catch urine
(CCU) and discharge on ABs if urine
dip positive
Well FWS 2-24mo
Options
A. 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 2-24mo
Options
A. 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 2-24mo
Options
A. 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
D. 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
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?
Will this well child get septic?
How common is paediatric urosepsis?
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
Will this well child get septic?
Evidence that paediatric urosepsis, especially outside
neonatal age is RARE
Will this well child get septic?
Evidence that paediatric urosepsis, especially outside
neonatal age is RARE
60% due to bacteraemia and respiratory causes
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
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%
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
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.
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
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
Will this well child get septic?
Paediatric urosepsis is:
Rare
Not particularly fatal
Unlikely to rapidly progress from uncomplicated UTI
Will this well child get septic?
Probably not…
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 pyelonephritis
47%
Does UTI progress to scarring
15%
Phew, but what about scarring ?
?
?
Does UTI progress to pyelonephritis
47%
Does UTI progress to scarring
15%
Yes
&
Yes
DONE!
Causes
scarring:
test and treat
Hang on…is scarring bad?
Hang on…is scarring bad?
Old guidelines based on 2 studies
Gill 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 2000
Prospective, controlled, large
Long-term follow-up
Confirm rate of scarring with paediatric UTI
No clinically or statistically significant increased rate of CKD
or decreased GFR
Epidemiological data also
Hang on…is scarring bad?
Scarring sounds bad…
But we got the BOMB!
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
Natural History
No good data!!!!
?1908 German study – can’t find it!
Do antibiotics even work?
UTI
Pyelonephritis
Scarring
Sepsis
Symptoms
Natural History
Unpublished prospective cohort study
presented at 2000 Pediatric Academic
Societies Annual Meeting.
n= 3066 infants 0-3mo T 38°C
managed per physicians whim
some investigated, sent home, some
admitted, some treated
Statistical trickery
~54 UTIs never received treatment
2 infants subsequently diagnosed UTI
Neither bacteremic; both treated and
recovered uneventfully.
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
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 (?)
Scarring
Sepsis
Symptoms
Do antibiotics even work?
UTI (?)
Pyelonephritis (?)
Scarring
Sepsis
Symptoms
Do antibiotics even work?
UTI (?)
Pyelonephritis (?)
Scarring
Sepsis
Symptoms
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
Do antibiotics even work?
UTI (?)
Pyelonephritis (?)
Scarring
Sepsis
Symptoms
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 days
Latest: 287 children. No difference between early (<12h) AB
and delayed (up to 5h) AB groups
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
Prevention
Urosepsis rare in kids
Antibiotic complications common
Do antibiotics even work?
UTI (?)
Pyelonephritis (?)
Scarring (-)
Sepsis
Symptoms
Prevention
Urosepsis rare in kids
Antibiotic 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 media
Tonsillitis
Pharyngitis
Sinusitis
Drained abscess
Valvulopathy & dental procedures
Other minor infection
Other minor infection
First do no harm…
Anaphylaxis
Antibiotic associated diarrhoea
Pseudomembranous colitis
Drug eruptions
Antimicrobial resistance
First do no harm…
Anaphylaxis
Antibiotic associated diarrhoea
Pseudomembranous colitis
Drug eruptions
Antimicrobial 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.
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.
4 weeks old + fever
12mo 3x UTIs FWS
Documented VUR
16mo multiple congenital
abnormalities
CRT 4s
Looks unwell
Acquired immunodeficiency
On chemo
STOP TAKING THE PISS
2mo – 2 years
Fever < 4 days
FWS on detailed survey
Well by senior opinion
Minimal Sx
No PHx UTI
No risk factors
Lives within cooee
Access to follow up
Capable parents
STOP TAKING THE PISS
2mo – 2 years
Fever < 4 days
FWS on detailed survey
Well by senior opinion
Minimal Sx
No PHx UTI
No risk factors
LET THEM GO HOME
Lives within cooee Home clean catch
Access to follow up Store in fridge >4h
Capable parents Clear TCB advice
Open door policy
Ensure follow up