SP Wu, SN Wong

Abstract

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.

目的：一個兒童泌尿道感染處理的的臨床審核，以確認與已發表本地指導方針之間的偏差及該領域任何方面的進展。方法：回顧性綜述一個區域性醫院收住兒科病房小於 2 歲兒童的 2 個分組研究組別。根據已計畫的問卷獲取資料。第一個組別包括發熱但無感染竈的兒童。有關資料用來評估篩查泌尿道感染的合適性。第二個組別包括已診斷了泌尿道感染的兒童。診斷標準、治療及跟蹤的影像學檢查也作評估用。結果：第一部分：97 名病童入選。 87.6% 接受泌尿道感染篩查（23.7% 通過浸漬片及床邊顯微鏡檢查，63.9% 僅通過浸漬片檢查）。在經浸漬片和/或床邊顯微鏡初始陽性篩查之後，僅 44.4% 使用合適的尿液標本培養（膀胱穿刺/導尿管/中段尿）有適當的確診檢驗，儘管一半的病例有重複的袋裝尿篩查。對那些因入院時疾病情況而需要立即使用抗菌素的患者，為培養而留取合適的尿液則僅佔 60%。第二部分：76 名病童入選。泌尿道感染的診斷是基於合適的尿液標本培養陽性的佔 92.1%，但其中 5 例在事故及急診部門或私人診所由醫生處理，4 例（80%）的診斷是基於袋裝尿的培養。所有的患者接受合適的抗菌素治療（主要為頭孢呋辛）涵蓋了致病的微生物（主要為大腸桿菌屬）。超過 90% 患者接受了影像學檢查，用於尋找泌尿道的異常、膀胱輸尿管反流或疤痕，但等待檢查的時間長（均數：超聲 2 個月；腎泌尿路照影則 4-5 個月）。最後，臨床評估檔及父母的教育被發現較少是合適的。結論：雖然多數泌尿道感染的患者接受了合理的治療，但亦有需要進一步改善的地方。診斷也許有遺漏如（ 1）12% 的患者的尿液沒有被篩查；（2）63.9% 的患者沒有同時接受浸漬片和顯微鏡的檢查；（3）存在 40% 沒有例行尿液培養之前經驗性地給予抗菌素治療情況。當發現尿液檢查呈陽性，只是重複袋裝尿的篩查，也許會延遲泌尿道感染的診斷。而且，合理的尋找泌尿道異常的線索與教育父母，以及縮短泌尿系影像學檢查時間，也許可以阻止泌尿道感染的復發。