Auditing the Management of Childhood Urinary Tract Infections in a Regional Hospital
Aim: A clinical audit on urinary tract infection (UTI) management to identify deviations from published local guidelines and any areas of improvement. Method: Retrospective review of 2 cohorts of children below 2 years old admitted to paediatric wards of a regional hospital. Data were extracted according to structured questionnaires. The first cohort included children admitted for fever without foci of infection, and data were collected to evaluate the adequacy of screening for UTI. The second cohort included children with a diagnostic label of UTI. The diagnostic criteria, treatment and follow-up imaging tests were evaluated. Results: Part I: 97 children were recruited. UTI was screened in 87.6% (23.7% by both dipsticks and bedside microscopy and 63.9% by dipsticks only). After an initial positive screening by dipsticks and/or bedside microscopy, only 44.4% had appropriately definitive tests by culture of a proper urine specimen (bladder tap/catheter/clean catch urine) whereas half of the cases had repeated bag urine screening. For patients who needed antibiotics immediately due to ill conditions on admission, proper urine was collected for culture in only 60%. Part II: 76 patients were recruited. UTI diagnosis was based on positive culture from a proper urine specimen in 92.1%, but of the 5 cases managed by doctors in Accident & Emergency Department or private practice, 4 (80%) were based on bag urine culture. All patients received appropriate antibiotics (mainly cefuroxime) covering the causative organisms (mainly Escherichia coli). Radiological investigations were arranged in >90% of patients, to look for urological abnormalities, vesicoureteric reflux or scarring, but there was a long waiting time (mean 2 months for ultrasound and 4-5 months for micturating cystourethrogram). Lastly, the documentation of clinical assessment and parental education were found to be less than adequate. Conclusion: Though UTI was properly managed in most cases, areas of improvements were identified. The diagnosis might be missed by 1) not screening patients' urine in 12% of cases; 2) not doing both dipsticks and microscopy in 63.9% of cases; 3) not doing urine culture before empirical antibiotics therapy in 40% of such situations. UTI diagnosis might have been delayed by just repeating bag urine screening when it was already positive. Furthermore, UTI recurrences might be prevented by properly looking for clues of urological abnormalities and educating parents, and shortening the waiting time for urological imaging studies.
Keyword : Chinese children; Clinical audit; Clinical guidelines; Urinary tract infection
Urinary tract infection (UTI) is a common childhood infection affecting about 5% of febrile children.1 Previous surveys have documented wide variations in the diagnosis and treatment of UTI.2 Suggested guidelines on its management have been published in North America3 and Europe.4,5 A local guideline on management of UTI in children below 2 years of age was introduced in 2002 among the public hospitals. It has been disseminated via the Hospital Authority intranet, the Hong Kong Journal of Paediatrics6,7 and through the coordinators in each paediatric units. To assess the extent of implementation of the guidelines, we performed a clinical audit in a regional hospital, with the aim of identifying any deviations in the management practices from guideline recommendations and any opportunities of improving the quality of care to these patients.
Patients and Methods
The study was a retrospective review of the case notes of patients in the paediatric department of a regional hospital. Data were extracted by the authors according to two structured questionnaires.
Part I of the study aimed at evaluating the proper method to diagnose or exclude UTI in at risk children. Consecutive patients below 2 years of age admitted with fever (>38°C) without obvious foci of infection during the period 1st January to 31st January 2003 were studied. In accordance with previous Guidelines, patients with a clinical diagnosis of pharyngitis, upper respiratory infection or mild gastroenteritis without watery or blood stained stool were not considered as foci of infection and were included.6 The following audit points were evaluated:
Part II of the study aimed at evaluation of basis of diagnosis and subsequent management of patients with proven UTI. We recruited all patients aged less than 2 years who received the diagnosis of UTI for the first time in the same department during the period of 1st January to 31st December 2003. Patients with known history of underlying urological abnormalities before UTI diagnosis were excluded. The referred cases from other hospitals solely for investigations without subsequent follow-up at our clinic were also excluded. The following audit points were selected for review:
Results: Part 1
Of the 144 patients admitted for fever during the study period, 46 patients had definite foci of fever. One patient's record could not be retrieved. Hence 97 patients were recruited. There were 37 girls (38%) and 60 boys (62%), with ages ranging from 0.1 to 2 years (mean 1.5 years, median 1 year). Six (6.2%) had a final diagnosis of UTI. The clinical presentation of the recruited patients was summarised in Table 2.
Results: Part 2
During the period 1st January to 31st December 2003, 79 children below 2 years of age were coded to have a diagnosis of the first episode of UTI. Three hospital records could not be retrieved and hence 76 patients were recruited for evaluation. There were 20 girls and 56 boys with ages ranging from 0.03 to 1.77 years (median 0.31 years). Their clinical presentations were summarised in Table 3.
This is the first report of a clinical audit to assess the compliance to the local guidelines on the management of childhood UTI in a regional hospital since the guidelines were introduced two years ago. It is also part of our continuous effort to improve the quality of care to these patients through the audit cycle: i.e. compiling an agreed standard of practice, ensuring its dissemination and implementation, auditing any deviations in actual clinical practice, and hence identifying significant areas for improvement.
The findings of this audit showed that, in accordance with established guidelines, UTI was properly looked for in most young febrile children. The incidence of UTI in our sample was 6.2%. This was comparable to previous studies overseas.1,8 Almost all UTI children received appropriate antibiotics treatment and were given prophylactic antibiotics pending investigations, and almost all children received appropriate imaging investigations to look for urological abnormalities and vesicoureteric reflux. These findings were comparable to those in a survey on 32 hospitals in the United Kingdom reported by Verrier Jones in 2000 (see Table 6).2
However, the audit also revealed a number of noteworthy areas of deficiencies. Firstly only 87.6% of febrile children were screened for UTI. This was similar to a United Kingdom survey in which 81% of 746 infants at risk had urine examination for UTI.2 Another study from office paediatricians in the USA showed that only 57% of 3066 infants had urine examined for UTI.9 Though our results were comparable to these overseas surveys, it could be further improved.
Secondly the screening method was considered inadequate, namely by dipsticks only, in about 60% of children. This may be related to the uncertain time of collecting the bag urine samples from infants. When a fresh urine sample was available, dipsticks could be done immediately by the ward nurses, whereas urine microscopy had to be done by the on-call doctors who might be busy with other duties. Another possible reason was the widely held misconception that we can screen for UTI by dipsticks alone and only when it is positive that we should confirm UTI by urine microscopy. It must be pointed out that the sensitivity and specificity of urine dipsticks alone for leukocyte esterase and nitrite were 88-93% and 72-93% respectively. By combining urine microscopy and dipsticks tests one can increase the sensitivity to 99.8% with specificity of 70%.1,6 In other words, we would have missed 7-12% of genuine UTI cases if only dipsticks were done alone. In contrast, the UK survey showed that 64% of patients had urine collected by bag or clean-catch and sent for both urinalysis and culture.2 Though the sensitivity of this approach was high, the false positive rate of bag urine culture was also unacceptably high.1
Thirdly, when the screening tests were positive, urine was collected properly (by bladder tap, catheter or clean-catch) in only 40% whereas the same tests on bag urine were repeated a second time in the rest. Provided the urinalysis was performed properly, repeating it twice may just lead to a delay in diagnosing UTI and starting treatment with undesirable consequences.10,11
Fourthly, when antibiotics had to be given immediately to ill patients on admission, only 60% had properly collected urine for culture to confirm or exclude UTI as a cause. In the remaining 40% of patients, the chance of clarifying the diagnosis was missed as antibiotics will render the urine culture negative once treatment was started.
Fifthly, the few patients who had been diagnosed and treated by colleagues in Accident and Emergency departments or private practice had improper documentation by bag urine cultures only. This may indicate the lack of awareness of the current guidelines by doctors in other specialties, or the difficulty of obtaining urine by bladder tap or catheterisation in a non-inpatient setting. However we were unable to audit the UTI management in these settings as other departments or private doctors were involved.
In addition, the documentation of clinical signs and patient education were inadequate. As shown in Table 3, the presence or absence of many important physical findings was documented in <50% of charts. These abnormal findings may signify serious underlying renal abnormalities and call for accelerated investigations and surgical treatment.4 Failure to perform these simple clinical assessments may lead to serious consequence.
Similarly education of parents were documented in a minority of cases. The overall recurrence rate of symptomatic UTI was 15%.12 and the risk of renal scarring increases with the number of recurrent febrile UTI.13 Therefore adequate education to parents to ensure their early detection of recurrences is important to prevent late complications. Besides, adequate explanation about the reasons for doing follow-up investigation and giving prophylactic antibiotics are important to ensure compliance. Use of pamphlets is a good alternative to convey adequate and correct information to parents. However, pamphlets were document to be given in only 12% cases. However because of the retrospective nature of an audit, these results may be related to lack of documentation rather than a genuine failure of communication to parents.
Lastly, the long wait for follow up investigations (mean of 2 months for ultrasound scan and 4-5 months for MCUG) were considered unsatisfactory. It may delay the detection of renal abnormalities and their appropriate treatment. For those without VUR, prophylactic antibiotics had to be continued unnecessarily till the investigations were performed.
We should be aware that this clinical audit is retrospective with the usual limitations of any retrospective data collection. We covered only inpatients in the paediatric department, and may have missed those children managed in the Accident and Emergency Department and private clinics. We did not audit the detection of UTI in situations other than the febrile child. Because of the small sample size, we cannot audit the diagnosis of UTI in neonates and use of DMSA scan for diagnosis in highly suspicious cases of UTI which cannot be confirmed by urine culture. Lastly the findings of this audit have to be interpreted bearing in mind that clinical guidelines are for guidance only, and its recommendations are based on levels of evidence. Flexibility and deviations from the recommendations are possible in the clinical practice with proper documentation of the valid reasons behind such deviations.
In conclusion, this audit reveals some significant deviations from established guidelines on UTI management in young children. Areas needing improvement include ensuring urinalysis in ALL febrile children, adding urine microscopy to dipsticks tests, saving a catheter urine sample for culture when empirical antibiotics need to be given, and detailed documentation of clinical assessment and parental education before discharge of these patients. The findings in this survey can also serve as a baseline for comparison with future audits or with similar audits in other departments on the same topic.
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