Applying Quality Improvement Methodology to Standardize Pediatric Urinary Tract Infection Diagnosis and Management throughout a Healthcare System
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SUBMITTER: Baumer-Mouradian S
PROVIDER: S-EPMC11338250 | biostudies-literature | 2024 Jan
REPOSITORIES: biostudies-literature
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Project description:PurposeAccurate diagnosis of urinary tract infection in children is essential because children left untreated can experience permanent renal injury. We aimed to assess the diagnostic value of clinical features of pediatric urinary tract infection.MethodsWe performed a systematic review and meta-analysis of diagnostic test accuracy studies in ambulatory care. We searched the PubMed, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Health Technology Assessment, and Database of Abstracts of Reviews of Effects databases from inception to January 27, 2020 for studies reporting 2 × 2 diagnostic accuracy data for clinical features compared with urine culture in children aged <18 years. For each clinical feature, we calculated likelihood ratios and posttest probabilities of urinary tract infection. To estimate summary parameters, we conducted a bivariate random effects meta-analysis and hierarchical summary receiver operating characteristic analysis.ResultsA total of 35 studies (N = 78,427 patients) of moderate to high quality were included, providing information on 58 clinical features and 6 prediction rules. Only circumcision (negative likelihood ratio [LR-] 0.24; 95% CI, 0.08-0.72; n = 8), stridor (LR- 0.20; 95% CI, 0.05-0.81; n = 1), and diaper rash (LR- 0.13; 95% CI, 0.02-0.92; n = 1) were useful for ruling out urinary tract infection. Body temperature or fever duration showed limited diagnostic value (area under the receiver operating characteristic curve 0.61; 95% CI, 0.47-0.73; n = 16). The Diagnosis of Urinary Tract Infection in Young Children score, Gorelick Scale score, and UTIcalc (https://uticalc.pitt.edu) might be useful to identify children eligible for urine sampling.ConclusionsFew clinical signs and symptoms are useful for diagnosing or ruling out urinary tract infection in children. Clinical prediction rules might be more accurate; however, they should be validated externally. Physicians should not restrict urine sampling to children with unexplained fever or other features suggestive of urinary tract infection.
| S-EPMC8437566 | biostudies-literature
Project description:Healthcare-associated infections (HAI) are a critical public health problem, with 30 to 40% of infections related to the urinary tract system. These urinary tract infections (UTIs) are considered one of the most common microbial infections in hospital settings and everyday community contexts, where approximately 80% are highly correlated with urinary catheter insertion, i.e., catheter-associated urinary tract infections (CAUTIs). Considering that 15 to 25% of hospitalised patients need to be catheterised during their treatments and most CAUTIs are asymptomatic, it results in a tremendous challenge to provide an early diagnosis of CAUTI and therefore initiate its treatment. The lack of standardised methods as a first step for urine monitoring and early detection of UTIs is the driving force of this work, which aims to explore the potential of absorption and fluorescence spectroscopic methodologies to detect UTIs. Urine samples were used without any previous treatment to target the most straightforward testing protocol possible. In this work, we successfully developed a powerful methodology that combines ratiometric fluorescence spectroscopy measurements and transmittance at 600 nm to distinguish healthy urine from infected urine. The complementary use of fluorescence spectroscopy and transmittance is what makes the new methodology we propose such a powerful approach to monitor urine samples and provide early detection of UTIs since it provides a quantitative analysis of both healthy and infected urine.
| S-EPMC11768836 | biostudies-literature
Project description:Iatrogenic injury to the urinary tract, including the kidneys, ureters, bladder, and urethra, is a potential complication of surgical procedures performed in or around the retroperitoneal abdominal space or pelvis. While both diagnostic and interventional radiologists often play a central and decisive role in the identification and initial management of a variety of iatrogenic injuries, discussions of these injuries are often directed toward specialists such as urologists, obstetricians, gynecologists, and general surgeons whose procedures are most often implicated in iatrogenic urinary tract injuries. Interventional radiologic procedures can also be a source of an iatrogenic urinary tract injury. This review describes the clinical presentation, risk factors, imaging findings, and management of iatrogenic renal vascular and urinary tract injuries, as well as the radiologist's role in the diagnosis, treatment, and cause of these injuries.
| S-EPMC4447880 | biostudies-other
Project description:IntroductionDemands on residents' time during training make it difficult for them to engage consistently with a primary care curriculum. In response to this, the emergency medicine and critical care fields have successfully utilized podcasting to the point where a recent study showed US emergency medicine residents ranked podcasts as the best use of their time for extracurricular education.MethodsWe produced a 30-minute podcast on urinary tract infections from a primary care perspective, based on descriptors from Entrustable Professional Activity 4, "Manage acute common illnesses in the ambulatory setting." A moderator, a primary care pediatrician, and a pediatric nephrologist used a loose script of salient points, allowing for a natural evolution of the dialogue. The podcast was distributed to residents via email, along with a 7-question survey.ResultsThe survey was completed by 50 out of 84 residents. Ninety-two percent listened to all or part of the podcast, 98% found it educational, 93% enjoyed listening, and 74% felt more confident identifying and managing patients with possible urinary tract infections after listening. Ninety-six percent felt podcasts were a good alternative method for delivering this curriculum. One comment read, "This was great! It makes the information more accessible so that I can listen while working out or driving or just laying on the couch."DiscussionBased on this success, we are producing additional podcasts and will strive to keep them under 20 minutes, provide key summary points at the end, and improve ease of access by utilizing an RSS (rich site summary) feed.
| S-EPMC6464441 | biostudies-literature
Project description:The implementation of evidence-based treatments to deliver high-quality care is essential to meet the healthcare demands of aging populations. However, the sustainable application of recommended practice is difficult to achieve and variable outcomes well recognised. The NHS Institute for Innovation and Improvement Sustainability Model (SM) was designed to help healthcare teams recognise determinants of sustainability and take action to embed new practice in routine care. This article describes a formative evaluation of the application of the SM by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for Northwest London (CLAHRC NWL). Data from project teams' responses to the SM and formal reviews was used to assess acceptability of the SM and the extent to which it prompted teams to take action. Projects were classified as 'engaged,' 'partially engaged' and 'non-engaged.' Quarterly survey feedback data was used to explore reasons for variation in engagement. Score patterns were compared against formal review data and a 'diversity of opinion' measure was derived to assess response variance over time. Of the 19 teams, six were categorized as 'engaged,' six 'partially engaged,' and seven as 'non-engaged.' Twelve teams found the model acceptable to some extent. Diversity of opinion reduced over time. A minority of teams used the SM consistently to take action to promote sustainability but for the majority SM use was sporadic. Feedback from some team members indicates difficulty in understanding and applying the model and negative views regarding its usefulness. The SM is an important attempt to enable teams to systematically consider determinants of sustainability, provide timely data to assess progress, and prompt action to create conditions for sustained practice. Tools such as these need to be tested in healthcare settings to assess strengths and weaknesses and findings disseminated to aid development. This study indicates the SM provides a potentially useful approach to measuring teams' views on the likelihood of sustainability and prompting action. Securing engagement of teams with the SM was challenging and redesign of elements may need to be considered. Capacity building and facilitation appears necessary for teams to effectively deploy the SM.
| S-EPMC3827618 | biostudies-literature
Project description:Objective: To discuss the risk factors, microbial resistance rates, and pharmacotherapy, including antimicrobial choices and medication dosage regimens, for urinary tract infections (UTIs) in pediatric patients. Data Sources: A MEDLINE literature search (1985 to December 2017) was performed using the following keywords and associated medical subject headings: urinary tract infection, antimicrobial, treatment, and children. Study Selection and Data Extraction: Search was conducted to identify clinical trials, systematic reviews, and guidelines. Search was filtered to include studies with age range between birth and 18 years and published in English. Additional references were identified from selected review articles. Data Synthesis: In total, 27 studies investigating microbial resistance, 31 studies assessing antimicrobial efficacy, 34 studies describing prophylaxis, and 6 systematic reviews were included. The resistance patterns differed across age groups and affected the choice of empirical therapy. If pyelonephritis is suspected, empiric antimicrobials should have high urinary and sufficient parenchymal concentrations. Nitrofurantoin has low microbial resistance rates and can generally be used empirically for treating uncomplicated cystitis in children >1 month of age. Trimethoprim-sulfamethoxazole resistance has increased and should be avoided unless local susceptibility data are available. Certain patients with recurrent UTIs or renal abnormalities may require antimicrobial prophylaxis, which may be associated with adverse effects, such as intolerability or an increased risk of microbial resistance. Conclusion: The resistance pattern of uropathogens should be considered prior to initiating therapy. Controlled trials with large samples are needed to compare the treatment duration of various antimicrobial regimens and the specific role of prophylactic antimicrobials.
| S-EPMC5998439 | biostudies-other
Project description:ObjectivesTo determine the accuracy of the novel biomarker urinary neutrophil gelatinase-associated lipocalin (uNGAL) to diagnose urinary tract infections (UTIs) in febrile infants and young children.MethodsProspective cross-sectional study of febrile infants <3 months ( ≥ 38.0°C) and children 3 to 24 months (≥ 39.0°C) evaluated for UTIs. uNGAL levels, urinalysis, Gram-stain and culture were obtained. UTI was defined by colony counts.ResultsOf 260 patients, 35 (13.5%) had UTIs. Median uNGAL levels were 215.1 ng/mL (interquartile range: 100.3-917.8) and 4.4 ng/mL (interquartile range: 1.6-11.8) in the groups diagnosed with and without UTIs, respectively. The area under the receiver-operating characteristic curve for uNGAL was 0.978 (95% confidence interval [CI]: 0.948-1.000). At a threshold uNGAL level of 39.1 ng/mL, sensitivity was 97.1% (95% CI: 83.4-99.9) and specificity was 95.6% (95% CI: 91.7-97.7). uNGAL had higher sensitivity than the combination of leukocyte esterase (in trace or greater amounts) or nitrite (+) (97.1%, 95% CI: 83.4-99.9 vs 74.3%, 95% CI: 56.4-86.9), with similar specificity (95.6%, 95% CI: 91.7-97.7 vs 97.3%, 95% CI: 94.0-98.9). uNGAL had higher sensitivity than Gram-stain (97.1%, 95% CI: 83.4-99.9 vs 74.3%, 95%: CI: 56.4-86.9), with similar specificity (95.6%, 95% CI: 91.7-97.7 vs 100.0%, 95% CI: 97.9-100.0).ConclusionsuNGAL has substantial accuracy to identify those with and without UTIs in infants and young children. Further studies will need to confirm our findings and determine if uNGAL is a more cost-effective test than standard screening tests.
| S-EPMC6658088 | biostudies-literature
Project description:IntroductionPrimary headache is a common cause of pediatric emergency department (PED) visits. Without published guidelines to direct treatment options, various strategies lacking evidence are often employed. This study aims to standardize primary headache treatment in the PED by promoting evidence-based therapies, reducing nonstandard abortive therapies, and introducing dihydroergotamine (DHE) into practice.MethodsA multidisciplinary team developed key drivers, created a clinical care algorithm, and updated electronic medical record order sets. Outcome measures included the percentage of patients receiving evidence-based therapies, nonstandard abortive therapies, DHE given after failed first-line therapies, and overall PED length of stay. Process measures included the percent of eligible patients with the order set usage and medications received within 90 minutes. Balancing measures included hospital admissions and returns to the PED within 72 hours. Annotated control charts depicted results over time.ResultsWe collected data from July 2017 to December 2019. The percent of patients receiving evidence-based therapies increased from 69% to 73%. The percent of patients receiving nonstandard abortive therapies decreased from 2.5% to 0.6%. The percent of patients receiving DHE after failed first-line therapies increased from 0% to 37.2%. No untoward effects on process or balancing measures occurred, with sustained improvement for 14 months.ConclusionStandardization efforts for patients with primary headaches led to improved use of evidence-based therapies and reduced nonstandard abortive therapies. This methodology also led to improved DHE use for migraine headache resistant to first-line therapies. We accomplished these results without increasing length of stay, admission, or return visits.
| S-EPMC8322484 | biostudies-literature
Project description:PurposeThis study aimed to assess the feasibility of contrast-enhanced ultrasound (CEUS) for the diagnosis of acute pyelonephritis (APN) in pediatric patients with febrile urinary tract infection (UTI).Materials and methodsBetween March 2019 and January 2021, study participants with suspected UTI were assessed for APN using ultrasound. Parenchymal echogenicity changes, renal pelvis dilatation, and the presence of a focal suspected lesion were assessed using conventional grayscale ultrasound. The presence and location of a decreased perfusion area were evaluated using color Doppler ultrasound (CDUS) and CEUS. Agreement between each ultrasound examination and a 99mTc‒dimercaptosuccinic acid (DMSA) scan was assessed using the κ value, and the most visible period of the lesion was evaluated using CEUS.ResultsThis study enrolled 21 participants (median age, 8.0 months; range, 2.0-61.0 months) with isolated urinary tract pathogens. Five increased parenchymal echotextures (11.9%) and 14 renal pelvic dilatations (33.3%) were confirmed, but no focal lesions were detected on the grayscale images. CDUS and CEUS showed decreased local perfusion suggestive of APN in two and five kidneys, respectively. DMSA scan showed substantial agreement with CEUS findings (κ = 0.80, P = 0.010), but other grayscale and CDUS findings did not agree with DMSA scan results (P > 0.05). All lesions were best observed in the late parenchymal phase on CEUS.ConclusionCEUS can reveal renal perfusion defects in pediatric patients with suspected APN without radiation exposure or sedation; therefore, CEUS may be a feasible and valuable diagnostic technique.
| S-EPMC10075446 | biostudies-literature
Project description:BackgroundAs genetic testing increasingly integrates into the practice of nephrology, our understanding of the basis of many kidney disorders has exponentially increased. Given this, we recently initiated a Renal Genetics Clinic (RGC) at our large, urban children's hospital for patients with kidney disorders.MethodsGenetic testing was performed in Clinical Laboratory Improvement Amendments-certified laboratories using single gene testing, multigene panels, chromosomal microarray, or exome sequencing.ResultsA total of 192 patients were evaluated in this clinic, with cystic kidney disease (49/192) being the most common reason for referral, followed by congenital anomalies of the kidney and urinary tract (41/192) and hematuria (38/192). Genetic testing was performed for 158 patients, with an overall diagnostic yield of 81 out of 158 (51%). In the 16 out of 81 (20%) of patients who reached a genetic diagnosis, medical or surgical treatment of the patients were affected, and previous clinical diagnoses were changed to more accurate genetic diagnoses in 12 of 81 (15%) patients.ConclusionsOur genetic testing provided an accurate diagnosis for children and, in some cases, led to further diagnoses in seemingly asymptomatic family members and changes to overall medical management. Genetic testing, as facilitated by such a specialized clinical setting, thus appears to have clear utility in the diagnosis and counseling of patients with a wide range of kidney manifestations.
| S-EPMC8785738 | biostudies-literature