Veena Gonuguntla MD Mentor: Robert Haws MD

1. Provider Satisfaction in assessing evidence based guidelines for urinary tract infection in children Veena Gonuguntla MD Mentor: Robert Haws MD

2. Objective of this project • To provide evidence based practice guidelines and assess the provider satisfaction in the management of urinary tract infections in childhood.

3. Background • The use of standardized protocols in the clinical setting is gaining wide spread acceptance. • These protocols may result in improved patient care, satisfaction and cost savings. • The lack of guidelines can result in treatment delays and failures as well as excessive antibiotic usage.

4. UTI statistics • UTI affects up to 3% of children in the US annually. • It is reported as second most common infection in children. • Accounts for about 0.7 % of total office visits. • Emergency visits include 5% - 14% of physician encounters for pediatric UTI.

5. Statistics cont’d…. • Data from national ambulatory medical care survey showed that more than 1.1 million annual physician office visits associated with UTI as primary diagnosis. • About 1.4 million annual office visits associated with UTI as any listed diagnosis. • Inpatient hospitalization is required in 2% - 3% of cases accounting ~ 36000 admissions in 2000

6. Financial Statistics • The cost of hospitalization for UTI amounts to $180 million annually. • True financial burden is much higher as it includes • cost of outpatient services • Imaging • other diagnostic evaluations • long term complications • management of associated conditions that increase the frequency and morbidity of UTI.

7. Organisms associated with UTI Gram negative organisms • Escherichia coli > 80% • Klebsiella species • Proteus – common in males • Enterobacter species < 2% • Pseudomonas species < 2% Gram positive organisms • Enterococci species • Staphylococcus saprophyticus • Staph. aureus (uncommon) • Group B strep (uncommon)

8. E-coli Resistance • E coli often carry multi drug resistant plasmids and under stress also can transfer these plasmids to other species. • Marked increase in E coli resistance is occurring over the last decade to various antibiotics including pencillins, cephalosporins, Trimethoprim - sulfamethoxazole etc. • Treatment usually is based on local resistance rates / patterns.

9. What is in literature? • Only available UTI guidelines in AAP are from 1999 and only available for < 2 year old infants • No recent updated guidelines in AAP for UTI. • Controversies regarding use of prophylaxis, regarding imaging after first UTI, admission criteria, treatment options and follow up of UTI.

10. Study Design Comprehensive search and analysis of medical literature. Reviewing the guidelines Developing algorithm Distribution of algorithm to clinicians. Family practitioners Adolescent medicine Nurse practitioners Pediatricians Neonatologists Emergency medicine Nephro/Urologists

11. Where am I currently in this project? • Searched literature available on management of UTI. • Reviewed the available protocols. • Selected the guidelines from Cincinnati Children’s hospital website which are found to be most updated and evidence based. • Developed Pre and Post assessment questionnaire to assess providers.

12. Algorithm

13. Algorithm cont’d….

14. What’s next…. • Sending pre-questionnaire to clinicians. • Distribution of the UTI protocol along with evidence to each step of the protocol to providers in Marshfield Clinic setting. • Assessment of provider satisfaction after 6 months of distribution by using ZoomerangTM.

15. Assessment questionnaire Pre Protocol Questionnaire.

16. Assessment questionnaire Post Protocol Questionnaire.

17. Follow up • Analyze the data • Put the data together and submit to AAP • As a next project will consider to analyze the treatment success with and without protocols.

18. Difficulties anticipated • Controversies regarding diagnosis, treatment or evaluation and questions will be raised (Algorithm will have a literature proof and is evidence based available so far) • Parents/ patients acceptance to different treatment approach. • Clinician compliance • Patient compliance

19. Expectations • Empowers health care provider to consistently treat and follow with the most updated evidence based guidelines. • Identification of co-morbidities/risk factors. • Long term benefits includes decreased antibiotic resistance, cost-effectiveness, accurate investigations.

20. References • AAP : Practice parameters : Pediatrics 103(4 Pt 1) : 843-52, 1999. • NICE guidelines. • WHO guidelines. • NIH statistics on UTI. • Cincinnati Children's Hospital medical center guidelines for UTI. • And various research publication as below • Wheeler, D. M.; Vimalachandra, D.; Hodson, E. M.; Roy, L. P.; Smith, G. H.; and Craig, J. C.: Interventions for primary vesicoureteric reflux. Cochrane Database Syst Rev, (3): • Wennerstrom, M.; Hansson, S.; Jodal, U.; and Stokland, E.: Primary and acquired renal scarring in boys and girls with urinary tract infection. J Pediatr, 136(1): 30-4, 2000c, [C] • Smith, E. M., and Elder, J. S.: Double antimicrobial prophylaxis in girls with breakthrough urinary tract infections. Urology, 43(5): 708-12; discussion 712-3, 1994, [D]

21. References Cont’d… • Lohr, J. A.; Portilla, M. G.; Geuder, T. G.; Dunn, M. L.; and Dudley, S. M.: Making a presumptive diagnosis of urinary tract infection by using a urinalysis performed in an on-site laboratory. J Pediatr, 122(1): 22-5, 1993, [C] • Lin, K. Y.; Chiu, N. T.; Chen, M. J.; Lai, C. H.; Huang, J. J.; Wang, Y. T.; and Chiou, Y. Y.: Acute pyelonephritis and sequelae of renal scar in pediatric first febrile urinary tract infection. Pediatr Nephrol, 18(4): 362-5, 2003, [C] • Ismaili, K.; Avni, F. E.; Martin Wissing, K.; and Hall, M.: Long-term clinical outcome of infants with mild and moderate fetal pyelectasis: validation of neonatal ultrasound as a screening tool to detect significant nephrouropathies. J Pediatr, 144(6): 759-65, 2004, [C] • Does antibiotic prophylaxis prevent renal scarring in children with vesicoureteral reflux? -Jack S Elder • Boreland, P. C., and Stoker, M.: Dipstick analysis for screening of paediatric urine. J Clin Pathol, 39(12): 1360-2, 1986, [C] • Beetz, R.: May we go on with antibacterial prophylaxis for urinary tract infections? Pediatr Nephrol, 21(1): 5-13, 2006, [S]....etc

22. Questions???

23. Thank you !!!