Urinary Imaging Findings in Young Infants With Bacteremic Urinary Tract Infection.

OBJECTIVES: To describe renal ultrasound (RUS) and voiding cystourethrogram (VCUG) findings and determine predictors of abnormal imaging in young infants with bacteremic urinary tract infection (UTI). METHODS: We used retrospective data from a multicenter sample of infants younger than 3 months with bacteremic UTI, defined as the same pathogenic organism in blood and urine. Infants were excluded if they had any major comorbidities, known urologic abnormalities at time of presentation, required intensive unit care, or had no imaging performed. Imaging results as stated in the radiology reports were categorized by a pediatric urologist. RESULTS: Of the 276 infants, 19 were excluded. Of the remaining 257 infants, 254 underwent a RUS and 224 underwent a VCUG. Fifty-five percent had ≥1 RUS abnormalities. Thirty-four percent had ≥1 VCUG abnormalities, including vesicoureteral reflux (VUR, 27%), duplication (1.3%), and infravesicular abnormality (0.9%). Age <1 month, male sex, and non-Escherichia coli organism predicted an abnormal RUS, but only non-E coli organism predicted an abnormal VCUG. Seventeen of 96 infants (17.7%) with a normal RUS had an abnormal VCUG: 15 with VUR (Grade I-III = 13, Grade IV = 2), 2 with elevated postvoid residual, and 1 with infravesical abnormality. CONCLUSIONS: Although RUS and VCUG abnormalities were common in this cohort, the frequency and severity were similar to previous studies of infants with UTIs in general. Our findings do not support special consideration of bacteremia in imaging decisions for otherwise well-appearing young infants with UTI.

Look Who's Talking: Comparing Perceptions Versus Direct Observations in Family-Centered Rounds.

BACKGROUND AND OBJECTIVES: Family-centered rounds (FCR) are an important and recommended component of pediatric hospital care. This study compares direct observations versus perceptions and ideals of who talks during FCR. METHODS: A silent investigator observed FCR and noted who spoke, time in patient rooms, nurse and family presences, and patient information. After the observation period, the medical team was offered an anonymous survey regarding typical and ideal usage of time on FCR. Data analysis included general linear models and analysis of variance tests. RESULTS: Thirty rounding sessions involving 234 encounters of FCR over a 12-week period were analyzed. On average, teams spent 7 minutes in each patient room and approximately the same amount of time outside of the room. Attending physicians were the dominant medical speakers during rounds (30.8%), and nurses spoke the least (2%). When inside a patient room, there was no significant difference between the percentage of time that attending physicians spoke (25.6%) and that of families and patients (23.0%). The surveys revealed that the medical team consistently underestimated the percentage of time attending physicians talked and desired attending physicians to talk less. They also overestimated the time spent in the patient rooms, the time families talked, and nurse presence during rounds and desired an increase in each of these areas. CONCLUSIONS: The medical teams' perceptions of FCR do not reflect clinical observations. Medical teams believe and desire that attending physicians talk less and families and nurses talk more than observations reveal.

Bacteraemic urinary tract infection: management and outcomes in young infants.

OBJECTIVES: To determine predictors of parenteral antibiotic duration and the association between parenteral treatment duration and relapses in infants <3 months with bacteraemic urinary tract infection (UTI). DESIGN: Multicentre retrospective cohort study. SETTING: Eleven healthcare institutions across the USA. PATIENTS: Infants <3 months of age with bacteraemic UTI, defined as the same pathogenic organism isolated from blood and urine. MAIN OUTCOME MEASURES: Duration of parenteral antibiotic therapy, relapsed UTI within 30 days. RESULTS: The mean (±SD) duration of parenteral antibiotics for the 251 included infants was 7.8 days (±4 days), with considerable variability between institutions (mean range 5.5-12 days). Independent predictors of the duration of parenteral antibiotic therapy included (coefficient, 95% CI): age (-0.2 days, -0.3 days to -0.08 days, for each week older), year treated (-0.2 days, -0.4 to -0.03 days for each subsequent calendar year), male gender (0.9 days, 0.01 to 1.8 days), a positive repeat blood culture during acute treatment (3.5 days, 1.2-5.9 days) and a non-Escherichia coli organism (2.2 days, 0.8-3.6 days). No infants had a relapsed bacteraemic UTI. Six infants (2.4%) had a relapsed UTI (without bacteraemia). The duration of parenteral antibiotics did not differ between infants with and without a relapse (8.2 vs 7.8 days, p=0.81). CONCLUSIONS: Parenteral antibiotic treatment duration in young infants with bacteraemic UTI was variable and only minimally explained by measurable patient factors. Relapses were rare and were not associated with treatment duration. Shorter parenteral courses may be appropriate in some infants.

Diagnostic accuracy of the urinalysis for urinary tract infection in infants <3 months of age.

BACKGROUND: The 2011 American Academy of Pediatrics urinary tract infection (UTI) guideline suggests incorporation of a positive urinalysis (UA) into the definition of UTI. However, concerns linger over UA sensitivity in young infants. Infants with the same pathogenic organism in the blood and urine (bacteremic UTI) have true infections and represent a desirable population for examination of UA sensitivity. METHODS: We collected UA results on a cross-sectional sample of 276 infants <3 months of age with bacteremic UTI from 11 hospital systems. Sensitivity was calculated on infants who had at least a partial UA performed and had ≥50 000 colony-forming units per milliliter from the urine culture. Specificity was determined by using a random sample of infants from the central study site with negative urine cultures. RESULTS: The final sample included 245 infants with bacteremic UTI and 115 infants with negative urine cultures. The sensitivity of leukocyte esterase was 97.6% (95% confidence interval [CI] 94.5%-99.2%) and of pyuria (>3 white blood cells/high-power field) was 96% (95% CI 92.5%-98.1%). Only 1 infant with bacteremic UTI (Group B Streptococcus) and a complete UA had an entirely negative UA. In infants with negative urine cultures, leukocyte esterase specificity was 93.9% (95% CI 87.9 - 97.5) and of pyuria was 91.3% (84.6%-95.6%). CONCLUSIONS: In young infants with bacteremic UTI, UA sensitivity is higher than previous reports in infants with UTI in general. This finding can be explained by spectrum bias or by inclusion of faulty gold standards (contaminants or asymptomatic bacteriuria) in previous studies.

Antibiotic and Diagnostic Discordance Between ED Physicians and Hospitalists for Pediatric Respiratory Illness.

BACKGROUND AND OBJECTIVE: Imperfect diagnostic tools make it difficult to know the extent to which a bacterial process is contributing to respiratory illness, complicating the decision to prescribe antibiotics. We sought to quantify diagnostic and antibiotic prescribing disagreements between emergency department (ED) and pediatric hospitalist physicians for children admitted with respiratory illness. METHODS: Manual chart review was used to identify testing, diagnostic, and antibiotic prescribing decisions for consecutive children admitted for respiratory illness in a winter (starting February 20, 2012) and a summer (starting August 20, 2012) season to a tertiary, freestanding children's hospital. Respiratory illness diagnoses were grouped into 3 categories: bacterial, viral, and asthma. RESULTS: A total of 181 children admitted for respiratory illness were studied. Diagnostic discordance was significant for all 3 types of respiratory illness but greatest for bacterial (P<.001). Antibiotic prescribing discordance was significant (P<.001), with pediatric hospitalists changing therapy for 93% of patients prescribed antibiotics in the ED, including stopping antibiotics altogether for 62% of patients. CONCLUSIONS: Significant diagnostic and antibiotic discordance between ED and pediatric hospitalist physicians exists for children admitted to the hospital for respiratory illness.

Summary of STARNet: Seamless Transitions and (Re)admissions Network.

The Seamless Transitions and (Re)admissions Network (STARNet) met in December 2012 to synthesize ongoing hospital-to-home transition work, discuss goals, and develop a plan to centralize transition information in the future. STARNet participants consisted of experts in the field of pediatric hospital medicine quality improvement and research, and included physicians and key stakeholders from hospital groups, private payers, as well as representatives from current transition collaboratives. In this report, we (1) review the current knowledge regarding hospital-to-home transitions; (2) outline the challenges of measuring and reducing readmissions; and (3) highlight research gaps and list potential measures for transition quality. STARNet met with the support of the American Academy of Pediatrics' Quality Improvement Innovation Networks and the Section on Hospital Medicine.

Pediatric hospitalists collaborate to improve timeliness of discharge communication.

OBJECTIVES: The transition of care from hospital to primary care provider (PCP) at discharge carries the potential for significant information loss. There is evidence that the timeliness and content of discharge communication are often unreliable during this handoff. Suboptimal transitions of care at discharge have been associated with adverse outcomes, and efficient solutions are required to transform the current state. Our specific aim was the achievement 90% documentation of hospitalist-PCP communication within 2 days of hospital discharge in < 12 months. METHODS: As part of a grassroots collaborative improvement organization, pediatric hospitalist groups engaged in parallel quality improvement projects to improve the timeliness and reliability of discharge communication at their local institutions. After an initial face-to-face meeting, e-mail and regular conference calls were used to promote shared effort and learning. The study period lasted 12 months, with > 16 weeks of continuous data required for inclusion. RESULTS: The mean rate of documentation of timely discharge communication across the collaborative increased from 57% to 85% over the study period. For the 7 hospitals that were able to collect > 16 weeks of data before July 2010, the mean rate of communication was > 90%. Participants reported that the context of the collaborative contributed to their success. CONCLUSIONS: Timely hospitalist-PCP communication was inconsistent at the beginning of the study. This low-resource quality improvement collaborative was able to achieve rapid improvement and resulted in improved perceptions of quality improvement knowledge among participants.

Quality improvement research in pediatric hospital medicine and the role of the Pediatric Research in Inpatient Settings (PRIS) network.

Pediatric hospitalists care for many hospitalized children in community and academic settings, and they must partner with administrators, other inpatient care providers, and researchers to assure the reliable delivery of high-quality, safe, evidence-based, and cost-effective care within the complex inpatient setting. Paralleling the growth of the field of pediatric hospital medicine is the realization that innovations are needed to address some of the most common clinical questions. Some of the unique challenges facing pediatric hospitalists include the lack of evidence for treating common conditions, children with chronic complex conditions, compressed time frame for admissions, and the variety of settings in which hospitalists practice. Most pediatric hospitalists are engaged in some kind of quality improvement (QI) work as hospitals provide many opportunities for QI activity and innovation. There are multiple national efforts in the pediatric hospital medicine community to improve quality, including the Children's Hospital Association (CHA) collaboratives and the Value in Pediatrics Network (VIP). Pediatric hospitalists are also challenged by the differences between QI and QI research; understanding that while improving local care is important, to provide consistent quality care to children we must study single-center and multicenter QI efforts by designing, developing, and evaluating interventions in a rigorous manner, and examine how systems variations impact implementation. The Pediatric Research in Inpatient Setting (PRIS) network is a leader in QI research and has several ongoing projects. The Prioritization project and Pediatric Health Information System Plus (PHIS+) have used administrative data to study variations in care, and the IIPE-PRIS Accelerating Safe Sign-outs (I-PASS) study highlights the potential for innovative QI research methods to improve care and clinical training. We address the importance, current state, accomplishments, and challenges of QI and QI research in pediatric hospital medicine; define the role of the PRIS Network in QI research; describe an exemplary QI research project, the I-PASS Study; address challenges for funding, training and mentorship, and publication; and identify future directions for QI research in pediatric hospital medicine.

Diagnostic and therapeutic challenges of childhood brucellosis in a nonendemic country.

OBJECTIVE: We sought [corrected] to define the current epidemiology, clinical manifestations, and course of childhood brucellosis in the United States. METHODS: A retrospective chart review was performed of 20 patients who received a diagnosis of brucellosis over a period of 13 years at a large, tertiary care children's hospital in Dallas, Texas. Diagnostic criteria, epidemiology, clinical presentations, and outcomes were recorded. RESULTS: Ninety-five percent of the patients had a recent history of either travel to Mexico or ingestion of unpasteurized milk products from Mexico. Fever was an initial complaint in 80% of the patients, and 50% of the patients presented with arthritis. Diagnosis was made via the identification of Brucella melitensis in the blood cultures of 18 patients. Five patients experienced relapse, and 3 experienced treatment failure. CONCLUSIONS: Childhood brucellosis in the United States is now an imported disease, primarily from Mexico. In the context of this epidemiologic link, the diagnosis should be entertained for a patient who presents with signs of systemic inflammation and arthritis. Therapeutic challenges remain.