UTI for PMH.ppt

UTI for PMH Prof Mike South UTI for Residents www.mikesouth.org.au Prof Mike South UTI for Residents 1 Case Emergency Dept - Friday pm • 6 month male infant • fever • feeding less than usual • single vomit • smelly wet nappies Examination • T 39.4C tymp • not very unwell rest of history and examination unremarkable ? Prof Mike South UTI for Residents METHODS FOR URINE COLLECTION • • • • • Mid-stream urine Self adhesive urine bag “Clean” catch Bladder catheterization Suprapubic aspiration (SPA) Prof Mike South UTI for Residents 2 Mid-stream urine • 108 cfu/L (105 cfu/mL) • contamination • sensitivity / specificity trade off • Void on request Prof Mike South UTI for Residents Bag urine Prof Mike South UTI for Residents 3 Bag urine • High rate of contamination (>50%) • Very poor predictive power for UTI • Should not be used to diagnose UTI • May have role in excluding UTI in low-risk situations Prof Mike South UTI for Residents “Clean” catch Prof Mike South UTI for Residents 4 “Clean” catch Prof Mike South UTI for Residents Prof Mike South UTI for Residents 5 “Clean” catch Accuracy of clean-catch urine collection in infancy Journal of Pediatrics December 1999 • Volume 135 • Number 6 • p765 to p767 Paired CCU and SPA • 80% success in 1 hour with correct technique • A false-positive rate of 5% Prof Mike South UTI for Residents Catheter Specimen • Significant contamination rates (unknown) • Poor predictive power for UTI (unknown) • ? CFU cut-off (RCH handbook 105 cfu/L) • One paired SPA/CSU study from 1959. “Cultures correlated” Prof Mike South UTI for Residents 6 Suprapubic aspirate Prof Mike South UTI for Residents Prof Mike South UTI for Residents 7 Suprapubic aspirate Pros • Very low contamination rate • High predictive power for UTI Cons • Success rate ~50% Prof Mike South UTI for Residents Bard BladderScan™ Prof Mike South UTI for Residents 8 RESULTS Blind Total (n) Success 36 44% Ultrasound 39 79% * Relative chance of success 1.8 P=0.004 * For 10mls. Better than 90% for 20mls Prof Mike South UTI for Residents SPA vs CSU Diagnostic confidence SPA Gold standard CSU OK if heavy pure growth with supportive WCC Many cultures indeterminate Complications Haematuria (benign) Bowel perforation (benign) Haematuria (benign) Urethral trauma UTI Discomfort Success ? 40-50% ? >90% >90% Prof Mike South UTI for Residents 9 Case continued • SPA obtained (with US) Prof Mike South UTI for Residents pH specific gravity glucose ketones blood protein urobilinogen bilirubin leukocyte esterase nitrite D Prof Mike South UTI for Residents 10 Dipsticks Leukocyte esterase Moderate correlation with # WBCs False negatives? False positives? Nitrite Good prediction +ve culture results False negatives? False positives? Prof Mike South UTI for Residents Dipsticks Leukocyte esterase Moderate correlation with # WBCs False negatives? False positives? Nitrite Good correlation culture results False negatives? False positives? Prof Mike South UTI for Residents 11 Dipsticks Leukocyte esterase Low/mod positive and negative predicted values Nitrite Good positive predicted values Weak negative predicted values Prof Mike South UTI for Residents Dipsticks Leukocyte esterase Low/mod positive and negative predicted values Always send urine for culture if UTI suspected In some studies dipsticks miss 40-50% of UTI Nitrite Good positive predicted values Weak negative predicted values Prof Mike South UTI for Residents 12 Case continued • SPA obtained (with US) • ++ Nitrites, ++ Leucocytes Prof Mike South UTI for Residents R Prof Mike South UTI for Residents 13 Case continued • • • • • SPA obtained (with US) ++ Nitrites, ++ Leucocytes ? Admit ? Other sepsis Ix ? Which IV antibiotics Enterococcus Staphylococcus saprophyticus, Streptococcus group B, E coli. Klebsiella species Proteus species Pseudomonas aeruginosa Prof Mike South UTI for Residents Case continued • • • • • • SPA obtained (with US) ++ Nitrites, ++ Leucocytes ++ WBC, + Gram negative Rods >108/L cfu E Coli On Benzylpen & Gent Still febrile Prof Mike South UTI for Residents 14 Case continued • Radiological investigations?? Prof Mike South UTI for Residents Background – “Standard Investigations” MCU Renal Ultrasound IVP Nuclear Imaging Prof Mike South UTI for Residents 15 Background • Simple view 10 – 15 years ago VUR + UTI “Reflux nephropathy” long-term risk of hypertension & renal failure + Logic: Need to investigate / intervene to reduce this future risk Prof Mike South UTI for Residents Results – Invasive Investigations Prof Mike South UTI for Residents 16 Results – Invasive Investigations – total numbers Invasive tests Total number nationwide Invasive tests Total Government $ Contribution at 2008 MBS fees 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 14,079 $2,000,000 $2.032M $1,500,000 MCU NM IVP MCU NM $1,000,000 4,941 $500,000 $0.739M IVP $- peak year 1998/9 last year 2006/7 peak year 1998/9 last year 2006/7 In same 10 year period 3% increase in number of children <15 years of age Prof Mike South UTI for Residents Results – Interstate variation in 2006/7 Number of Renal US / 100,000 Population 0-4 years 2006-2007 Renal US 90 80 78 70 Number of Nuc Meds / 100,000 Population 0-4 years 2006-2007 NM 4,000 3,500 3,000 2,500 2,000 1,500 1,000 500 0 3,673 3,637 3,573 2,898 2,645 2,463 2,319 60 56 36 30 17 14 12 2,097 50 40 30 20 10 0 SA NSW VIC ACT WA TAS QLD NT NSW WA QLD SA NT TAS VIC Number of MCUs / 100,000 Population 0-4 years 2006-2007 MCU Number of IVPs / 100,000 Population 0-4 years 2006-2007 450 400 350 300 250 200 150 100 50 0 405 300 10 9 8 8.5 IVP 293 283 235 173 139 41 7 6 5 4 3 2 1 0 2 1.5 1 0.5 VIC 0 TAS 0 ACT 0 NT NSW SA WA ACT NT QLD VIC TAS NSW WA QLD SA Prof Mike South UTI for Residents 17