Provider Satisfaction in Provider Satisfaction in assessing evidence based assessing evidence based

guidelines for urinary tract guidelines for urinary tract infection in childreninfection in children

Veena Gonuguntla MDVeena Gonuguntla MD

Mentor: Robert Haws MDMentor: Robert Haws MD

Objective of this projectObjective of this project

To provide evidence based practice guidelines To provide evidence based practice guidelines and assess the provider satisfaction in the and assess the provider satisfaction in the management of urinary tract infections in management of urinary tract infections in childhood. childhood.

BackgroundBackground

The use of standardized protocols in the The use of standardized protocols in the clinical setting is gaining wide spread clinical setting is gaining wide spread acceptance. acceptance.

These protocols may result in improved patient These protocols may result in improved patient care, satisfaction and cost savings.care, satisfaction and cost savings.

The lack of guidelines can result in treatment The lack of guidelines can result in treatment delays and failures as well as excessive delays and failures as well as excessive antibiotic usage.antibiotic usage.

UTI statisticsUTI statistics

UTI affects up to 3% of children in the US UTI affects up to 3% of children in the US annually.annually.

It is reported as second most common It is reported as second most common infection in children.infection in children.

Accounts for about 0.7 % of total office visits.Accounts for about 0.7 % of total office visits. Emergency visits include 5% - 14% of Emergency visits include 5% - 14% of

physician encounters for pediatric UTI.physician encounters for pediatric UTI.

Statistics cont’d….Statistics cont’d….

Data from national ambulatory medical care Data from national ambulatory medical care survey showed that more than 1.1 million survey showed that more than 1.1 million annual physician office visits associated with annual physician office visits associated with UTI as primary diagnosis.UTI as primary diagnosis.

About 1.4 million annual office visits About 1.4 million annual office visits associated with UTI as any listed diagnosis.associated with UTI as any listed diagnosis.

Inpatient hospitalization is required in 2% - Inpatient hospitalization is required in 2% - 3% of cases accounting ~ 36000 admissions in 3% of cases accounting ~ 36000 admissions in 20002000

Financial StatisticsFinancial Statistics

The cost of hospitalization for UTI amounts to $180 The cost of hospitalization for UTI amounts to $180 million annually.million annually.

True financial burden is much higher as it includes True financial burden is much higher as it includes cost of outpatient servicescost of outpatient services ImagingImaging other diagnostic evaluationsother diagnostic evaluations long term complicationslong term complications management of associated conditions that increase the management of associated conditions that increase the

frequency and morbidity of UTI.frequency and morbidity of UTI.

Organisms associated with UTI

Gram negative organismsGram negative organisms Escherichia coli > 80%Escherichia coli > 80% Klebsiella speciesKlebsiella species Proteus – common in malesProteus – common in males Enterobacter species < 2%Enterobacter species < 2% Pseudomonas species < 2%Pseudomonas species < 2%Gram positive organismsGram positive organisms Enterococci speciesEnterococci species Staphylococcus saprophyticusStaphylococcus saprophyticus Staph. aureus (uncommon)Staph. aureus (uncommon) Group B strep (uncommon)Group B strep (uncommon)

E-coli ResistanceE-coli Resistance

E coli often carry multi drug resistant plasmids and E coli often carry multi drug resistant plasmids and under stress also can transfer these plasmids to other under stress also can transfer these plasmids to other species.species.

Marked increase in E coli resistance is occurring over Marked increase in E coli resistance is occurring over the last decade to various antibiotics including the last decade to various antibiotics including pencillins, cephalosporins, Trimethoprim - pencillins, cephalosporins, Trimethoprim - sulfamethoxazole etc.sulfamethoxazole etc.

Treatment usually is based on local resistance rates / Treatment usually is based on local resistance rates / patterns.patterns.

What is in literature?What is in literature?

Only available UTI guidelines in AAP are Only available UTI guidelines in AAP are from 1999 and only available for < 2 year old from 1999 and only available for < 2 year old infantsinfants

No recent updated guidelines in AAP for UTI.No recent updated guidelines in AAP for UTI. Controversies regarding use of prophylaxis, Controversies regarding use of prophylaxis,

regarding imaging after first UTI, admission regarding imaging after first UTI, admission criteria, treatment options and follow up of criteria, treatment options and follow up of UTI.UTI.

Study DesignStudy Design

Comprehensive search and analysis of medical literature.

Reviewing the guidelines

Developing algorithm

Distribution of algorithm to clinicians.

Adolescent medicinePediatricians

NeonatologistsEmergencymedicine

Nephro/Urologists

Nursepractitioners

Family practitioners

Where am I currently in this Where am I currently in this project?project?

Searched literature available on management Searched literature available on management of UTI. of UTI.

Reviewed the available protocols.Reviewed the available protocols. Selected the guidelines from Cincinnati Selected the guidelines from Cincinnati

Children’s hospital website which are found to Children’s hospital website which are found to be most updated and evidence based.be most updated and evidence based.

Developed Pre and Post assessment Developed Pre and Post assessment questionnaire to assess providers.questionnaire to assess providers.

AlgorithmAlgorithm

Algorithm cont’d….Algorithm cont’d….

What’s next….What’s next….

Sending pre-questionnaire to clinicians.Sending pre-questionnaire to clinicians. Distribution of the UTI protocol along with Distribution of the UTI protocol along with

evidence to each step of the protocol to evidence to each step of the protocol to providers in Marshfield Clinic setting.providers in Marshfield Clinic setting.

Assessment of provider satisfaction after 6 Assessment of provider satisfaction after 6 months of distribution by using Zoomerangmonths of distribution by using ZoomerangTM..

Assessment questionnaireAssessment questionnaire

Pre Protocol Questionnaire.Pre Protocol Questionnaire.

Strongly Agree

Agree No Opinion Disagree Strongly Disagree

1. I like to use protocols for childhood illnesses

2. I have used protocols for management of UTI previously.

3. I think following a protocol will be useful in management of diseases.

4. I think following protocols will be effective in managing illnesses.

5. I like to use a evidence based protocol for management of UTI.

Assessment questionnaireAssessment questionnaire

Post Protocol Questionnaire.Post Protocol Questionnaire.Strongly Agree Agree No Opinion Disagree Strongly Disagree

1. This protocol for UTI is easy to understand

2. This protocol is easy to follow.

3. This protocol is helpful for guiding, imaging and followup in children with UTI.

4. I will use this protocol for UTI management in future.

5. I think this protocol improved the quality of care of children with UTI.

6. I think similar protocols for childhood 6. I think similar protocols for childhood illnesses would be helpful for my illnesses would be helpful for my practice. practice.

Follow upFollow up

Analyze the data Analyze the data Put the data together and submit to AAPPut the data together and submit to AAP As a next project will consider to analyze the As a next project will consider to analyze the

treatment success with and without protocols.treatment success with and without protocols.

Difficulties anticipatedDifficulties anticipated

Controversies regarding diagnosis, treatment Controversies regarding diagnosis, treatment or evaluation and questions will be raised or evaluation and questions will be raised (Algorithm will have a literature proof and is (Algorithm will have a literature proof and is evidence based available so far)evidence based available so far)

Parents/ patients acceptance to different Parents/ patients acceptance to different treatment approach.treatment approach.

Clinician complianceClinician compliance Patient compliancePatient compliance

ExpectationsExpectations

Empowers health care provider to consistently Empowers health care provider to consistently treat and follow with the most updated treat and follow with the most updated evidence based guidelines.evidence based guidelines.

Identification of co-morbidities/risk factors.Identification of co-morbidities/risk factors. Long term benefits includes decreased Long term benefits includes decreased

antibiotic resistance, cost-effectiveness, antibiotic resistance, cost-effectiveness, accurate investigations.accurate investigations.

ReferencesReferences AAP : Practice parameters : AAP : Practice parameters : Pediatrics 103(4 Pt 1) : 843-52, 1999.Pediatrics 103(4 Pt 1) : 843-52, 1999. NICE guidelines.NICE guidelines. WHO guidelines.WHO guidelines. NIH statistics on UTI.NIH statistics on UTI. Cincinnati Children's Hospital medical center guidelines for UTI.Cincinnati Children's Hospital medical center guidelines for UTI. And various research publication as belowAnd 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]

References Cont’d…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

Questions???Questions???

Thank you !!!Thank you !!!