1. Stop taking the piss Luke Burman STOPPIT Queensland Autumn Symposium May 2015

2. 18mo boy fevers 1/7

3. No significant history otherwise Vaccinations UTD 18mo boy fevers 1/7

4. No significant history otherwise Vaccinations UTD 18mo boy fevers 1/7 T39.1 RR20 HR100 SpO2 98% CRT <2 Alert

5. No significant history otherwise Vaccinations UTD 18mo boy fevers 1/7 T39.1 RR20 HR100 SpO2 98% CRT <2 Alert Looks very well, smiling, iPhone+

6. No significant history otherwise Vaccinations UTD 18mo boy fevers 1/7 T39.1 RR20 HR100 SpO2 98% CRT <2 Alert Looks very well, smiling, iPhone+ Neither focus nor concern on detailed systems exam

7. No significant history otherwise Vaccinations UTD 18mo boy fevers 1/7 T39.1 RR20 HR100 SpO2 98% CRT <2 Alert Looks very well, smiling, iPhone+ Neither focus nor concern on detailed systems exam Past his bed time Grumpy pa(re)nts

8. No significant history otherwise Vaccinations UTD 18mo boy fevers 1/7 T39.1 RR20 HR100 SpO2 98% CRT <2 Alert Looks very well, smiling, iPhone+ Neither focus nor concern on detailed systems exam Past his bed time Grumpy pa(re)nts He’s been in ED 35mins

9. No significant history otherwise Vaccinations UTD 18mo boy fevers 1/7 T39.1 RR20 HR100 SpO2 98% CRT <2 Alert Looks very well, smiling, iPhone+ Neither focus nor concern on detailed systems exam Past his bed time Grumpy pa(re)nts He’s been in ED 35mins What do you do next?

11. 24

12. Well FWS 2-24mo

13. Options

14. Well FWS 2-24mo Options A.Keep in ED until clean catch urine (CCU) and discharge on ABs if urine dip positive

15. 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

16. 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

17. 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

18. So why do we take the piss…?

19. ?Because we always do ?Because guidelines say so

20. So why do we take the piss…? ?Because we always do ?Because guidelines say so ? To identify UTI…..so that we can treat it!!

21. 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

22. 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

23. 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

24. 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

25. 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

30. Anals of Emergency Medicine n

32. UTI in kids – big deal?

33. 8% of girls and 2% of boys are diagnosed with at least one UTI by the age of seven years.

34. 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”

35. 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????

36. 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.

37. Will this well child get septic?

38. and DIE!!!

39. Will this well child get septic? How common is paediatric urosepsis? and DIE!!!

40. 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!!!

41. Will this well child get septic? Evidence that paediatric urosepsis, especially outside neonatal age is RARE and DIE!!!

42. 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!!!

43. 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!!!

44. 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!!!

45. 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!!!

46. 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!!!

47. 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!!!

48. 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!!!

49. Will this well child get septic? Paediatric urosepsis is: Rare Not particularly fatal Unlikely to rapidly progress from uncomplicated UTI and DIE!!!

50. Will this well child get septic? Probably not… and DIE!!!

51. Phew, but what about scarring ?

52. ?Does UTI progress to pyelonephritis ?Does UTI progress to scarring

53. Phew, but what about scarring ? ?Does UTI progress to pyelonephritis 47% ?Does UTI progress to scarring 15%

54. Phew, but what about scarring ? ?Does UTI progress to pyelonephritis 47% ?Does UTI progress to scarring 15% Yes & Yes

55. DONE! Causes scarring: test and treat

56. Hang on…is scarring bad?

57. 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

58. 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

59. Hang on…is scarring bad? Scarring sounds bad…

60. But we got the BOMB!

61. Do antibiotics even work? UTI Pyelonephritis Scarring Sepsis Symptoms

62. Do antibiotics even work? UTI Pyelonephritis Scarring Sepsis Symptoms

63. Do antibiotics even work? UTI Pyelonephritis Scarring Sepsis Symptoms Natural History No good data!!!! ?1908 German study – can’t find it!

64. 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.

65. Do antibiotics even work? UTI (?) Pyelonephritis Scarring Sepsis Symptoms

66. Do antibiotics even work? UTI (?)Pyelonephritis Scarring Sepsis Symptoms

67. 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

68. Do antibiotics even work? UTI (?) Pyelonephritis (?) Scarring Sepsis Symptoms

69. Do antibiotics even work? UTI (?) Pyelonephritis (?)Scarring Sepsis Symptoms

70. 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 (?)Scarring Sepsis Symptoms

71. 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 days Latest: 287 children. No difference between early (<12h) AB and delayed (up to 5h) AB groups UTI (?) Pyelonephritis (?)Scarring Sepsis Symptoms

72. Do antibiotics even work? UTI (?) Pyelonephritis (?) Scarring (-) Sepsis Symptoms

73. Do antibiotics even work? UTI (?) Pyelonephritis (?) Scarring (-)Sepsis Symptoms

74. Do antibiotics even work? UTI (?) Pyelonephritis (?) Scarring (-)Sepsis Symptoms Prevention Urosepsis rare in kids Antibiotic complications common

75. Do antibiotics even work? UTI (?) Pyelonephritis (?) Scarring (-)Sepsis Symptoms Prevention Urosepsis rare in kids Antibiotic complications common Treatment

76. Do antibiotics even work? UTI (?) Pyelonephritis (?) Scarring (-) Sepsis (+/-) Symptoms

77. Do antibiotics even work? UTI (?) Pyelonephritis (?) Scarring (-) Sepsis (+/-)Symptoms

78. Do antibiotics even work? UTI (?) Pyelonephritis (?) Scarring (-) Sepsis (+/-)Symptoms Surpise! No data.

79. Do antibiotics even work? UTI (?) Pyelonephritis (?) Scarring (-) Sepsis (+/-) Symptoms (?)

80. What?! No bug killers?

81. Otitis media Tonsillitis Pharyngitis Sinusitis Drained abscess Valvulopathy & dental procedures Other minor infection

82. First do no harm… Anaphylaxis Antibiotic associated diarrhoea Pseudomembranous colitis Drug eruptions Antimicrobial resistance

83. First do no harm… Anaphylaxis Antibiotic associated diarrhoea Pseudomembranous colitis Drug eruptions Antimicrobial resistance MEDICALISATION OF MILD ILLNESS

84. PPV is important too… TestSn% (Range)Sp% (Range) Leukocyte esterase test83 (67-94)78 (64-92) Nitrite test53(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 above99.8 (99-100)70 (60-92)

85. PPV is important too… + PPV = 58%

86. PPV is important too… + =

87. Sterile pyuria: common Asymptomatic bacteruria – VARIABLE BETWEEN 0.5 AND 4% BOYS <<<<<girls – Usually cited as 2%

88. So, what’re you saying?

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

90. So, what’re you saying? Stop giving antibiotics to kids with UTI???????? Stop getting urine samples when UTI suspected???????

91. So, what’re you saying? Stop giving antibiotics to kids with UTI???????? Stop getting urine samples when UTI suspected??????? NO

92. What I am saying

93. 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.

94. 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.

95. 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

96. 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 KEEP IT FOR NOW

97. 4 weeks old + fever

98. 12mo 3x UTIs FWS

99. Documented VUR

100. 16mo multiple congenital abnormalities

101. CRT 4s

102. Looks unwell

103. Acquired immunodeficiency

104. On chemo

105. 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

106. LET THEM GO HOME Home clean catch Store in fridge >4h Clear TCB advice Open door policy Ensure follow up 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