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Transcript

The Big Picture on UTI · The SHEA Podcast

• 0:05
  SPEAKER_01: Jay is excited to launch the third podcast of this series, focusing on the big picture of urinary tract infections.
• 0:12
  SPEAKER_01: Our two panelists are Susan E.
• 0:14
  SPEAKER_01: Coffin, MD MPH, attending physician and clinical director at the Children's Hospital of Philadelphia, and Chris Dernich, MD PhD, MS, Chief of Medicine and Hospital Epidemiologist at the William S.
• 0:28
  SPEAKER_01: Middleton VA Hospital.
• 0:31
  SPEAKER_02: Well, Susan, really good to be talking with you today about a problem that I think you and I both encounter frequently in our practice.
• 0:39
  SPEAKER_02: So from your perspective in dealing with pediatrics, can can you kind of talk a little bit about the issue of UTI over diagnosis in in your population, particularly since I deal mostly with adults?
• 0:55
  SPEAKER_00: Sure.
• 0:56
  SPEAKER_00: And I think this is going to be what's fun about this conversation, Chris, is we both uh have perspectives that are pretty different on the patient population side of things, but I suspect we'll find some similarities in terms of where the challenges lie.
• 1:10
  SPEAKER_00: So for children, UTIs tend to be the second leading cause of antibiotic use and probably the second leading cause of antibiotic overuse in children who present for sick visits to the primary care doctors.
• 1:26
  SPEAKER_00: So clearly a major clinical challenge, and then also has the opportunity to be one of the areas we really try to improve our diagnosis and prescribing for, with the aim of improving overall antibiotic use.
• 1:42
  SPEAKER_00: Now, for adults, where does the problem sit in terms of all the different things an adult doctor has to care for?
• 1:48
  SPEAKER_02: Well, you know, it's really interesting that you you make you know that the comments about probability because those numbers are kind of spot on for adults as well.
• 1:58
  SPEAKER_02: Um, if you kind of look at national samples for clinics and emergency room settings, UTI is probably the second most commonly uh treated infection in those settings.
• 2:11
  SPEAKER_02: And when you go into the nursing home, UTI is probably the number one infection that that's being treated with antibiotic in those settings.
• 2:19
  SPEAKER_02: So it's actually surprising to me to hear how well aligned our numbers are for both adults and kids.
• 2:25
  SPEAKER_02: And certainly overtreatment is a huge problem for us, in particular when you look at the consequences of prescribing, where things like C.
• 2:35
  SPEAKER_02: difficile are increasingly being described in the outpatient setting.
• 2:40
  SPEAKER_02: And certainly when you look at nursing homes, C.
• 2:42
  SPEAKER_02: difficile probably is across all healthcare settings, probably the most commonly identified in long-term care.
• 2:50
  SPEAKER_02: Um, and a lot of that is being driven by antibiotic exposure in those settings.
• 2:55
  SPEAKER_00: And that's the same for us.
• 2:57
  SPEAKER_00: We noticed a real surge in the frequency of C.
• 3:01
  SPEAKER_00: difficile infection in children, which is not always thought of, and that it often is occurring in outpatients and often associated with prior treatment of a UTI.
• 3:12
  SPEAKER_00: So there's a lot of potential benefit to be gained, I think, from thoughtful discussions around improving our use of antibiotics in this domain.
• 3:23
  SPEAKER_02: So in my population, we we see a lot of issues with the ever-progressing resistance or climb towards resistant organisms that we see in certain patients who get repeatedly exposed to antibiotics for what clinicians think might be urinary tract infection, eventually culminating in infections that are almost impossible to treat, uh, things like vancomycin resistant enterococcus and candidal infections, often being what I call terminal events, so to speak.
• 3:57
  SPEAKER_02: Um how common is that in in the pediatric population?
• 4:02
  SPEAKER_00: It's increasingly seen.
• 4:04
  SPEAKER_00: One of the areas that we're beginning to understand is that the benefits of UTI prophylaxis, which is very commonly done in young children with the first UTI, really driven by old literature that it might reduce the risk of renal scarring, has been now shown to not actually reduce the risk of renal scarring.
• 4:27
  SPEAKER_00: And it does increase the risk of subsequent infections, both UTIs and non-UTIs, with resistant organisms.
• 4:35
  SPEAKER_00: So there's a bit of a debate going on as to how we think about antibiotic prophylaxis after UTI, as well as any antibiotic use and its implications for risk of resistant UTIs in the future.
• 4:50
  SPEAKER_00: One other area that I'm curious to hear your thoughts on is how discussions have evolved about when urine specimens should be sent for both urinalysis and urine culture.
• 5:01
  SPEAKER_00: This has been a big issue in PEADS because children are often difficult to assess in terms of localization of infection.
• 5:09
  SPEAKER_00: So urine is frequently sent without a lot of specific symptoms.
• 5:15
  SPEAKER_00: And I'd be really curious to hear what's going on in terms of adults around use of diagnostic tests and whether or not concerns around targeting for testing the most appropriate patients has emerged as a priority.
• 5:32
  SPEAKER_02: Yeah, I think you're hitting the nail on the head.
• 5:35
  SPEAKER_02: I think if you go out and you know survey a sample of clinicians and you ask them the question, should we be treating asymptomatic bacteria, you'll get a nearly uniform response that no, we shouldn't be treating asymptomatic bacteria.
• 5:51
  SPEAKER_02: But I think we've kind of missed the mark, so to speak, because of that issue.
• 5:56
  SPEAKER_02: I think most clinicians who are over-treating urinary tract infection really feel like they're treating symptomatic UTI.
• 6:04
  SPEAKER_02: And I think the problem really relates to kind of where clinicians are weighting their emphasis in that diagnostic pathway.
• 6:14
  SPEAKER_02: And I think the the big problems we find is that clinicians put too much weight on nonspecific symptoms, and they also put too much weight on the diagnostic accuracy of our currently available tests.
• 6:31
  SPEAKER_02: So one of the issues that we encounter, which I think is probably similar to what you encounter in in children, is with the cognitively impaired, frail elderly, it sometimes is difficult to figure out why there's a behavior change or a change in their baseline status.
• 6:52
  SPEAKER_02: And it often becomes kind of the de facto diagnosis or the scapegoat where you have an abnormal urinalysis, positive urine culture in the setting of a nonspecific presentation.
• 7:05
  SPEAKER_02: A UTI is kind of what clinicians reach for, even though there are probably a dozen other things that could be driving that change of behavior, uh, including medications, pain, changes in sensory input, all the things that we commonly worry about inducing delirium.
• 7:24
  SPEAKER_02: But because you know the abnormal UA and positive urine culture is so prevalent in this population, it it's almost easy to see how a clinician would want to reach for a diagnosis of UTI.
• 7:38
  SPEAKER_02: And I suspect that you encounter many of the same things with young children who have difficulty verbalizing.
• 7:45
  SPEAKER_00: Absolutely.
• 7:46
  SPEAKER_00: And just like the elderly and infirmed, the difficulties in localizing symptoms, a perceived fragility, all push clinicians, I think naturally, to want to be cautious.
• 8:00
  SPEAKER_00: Has there been a movement in the adult world to have a gateway between getting a urinalysis result and sending the sample on for urine culture?
• 8:13
  SPEAKER_00: In pediatrics, we've increasingly seen bifurcated testing algorithms where an order which might be for urinalysis and culture would be aborted, the culture would be aborted if the urinalysis did not demonstrate pyuria.
• 8:32
  SPEAKER_02: Yeah, I think that there's been some really interesting studies that have come out in the last couple of years around that kind of laboratory-based stratification.
• 8:44
  SPEAKER_02: Obviously, one of the problems that we encounter in in many settings is laboratories have kind of set up the converse of that, where they reflex to a culture anytime the urinalysis is abnormal.
• 8:59
  SPEAKER_02: But what you're really asking is avoiding a urine culture from being sent if the urinalysis is normal.
• 9:07
  SPEAKER_02: And I think labs need to be doing both, but clinicians put way too much emphasis on the lab results rather than focusing on the clinical picture.
• 9:18
  SPEAKER_02: And what I tell clinicians, particularly those who are treating frail elderly, is UTI is a clinical diagnosis, and laboratory tests have very little role in the positive diagnosis of UTI.
• 9:38
  SPEAKER_02: So I think they still have a role in ruling out an infection.
• 9:43
  SPEAKER_02: So if you have a normal urinalysis, and certainly if you have a negative culture, you've essentially excluded a diagnosis of UTI.
• 9:52
  SPEAKER_00: One of the things that I came across recently that I would be really interested to hear more about is some data apparently from adults showing that there's a subset of adults with uncomplicated UTIs who probably have real disease, but through behavioral management, can clear their UTI without antibiotics.
• 10:12
  SPEAKER_00: I was wondering if this is just a one-off small study or something that's really emerging in adult practice.
• 10:20
  SPEAKER_02: There certainly is a cohort of investigators who are calling for more studies to test that hypothesis, whether we can treat, you know, what are fairly convincing episodes of symptomatic UTI with kind of symptom relief interventions alone and avoiding antibiotic therapy entirely.
• 10:44
  SPEAKER_02: I think that this approach makes a large proportion of clinicians uncomfortable.
• 10:51
  SPEAKER_02: And there are some results accumulating from a large randomized controlled trial that was done in the Netherlands.
• 10:59
  SPEAKER_02: I think you'll still hear some people argue that it might be worth, you know, trying symptomatic relief alone.
• 11:06
  SPEAKER_02: But that being said, the the existing data suggests, you know, a substantial number of people managed with symptoms alone will progress without antibiotic therapy.
• 11:17
  SPEAKER_02: So I think it it probably will not be a direction that I see most clinicians, at least in the United States, going, is my sense.
• 11:26
  SPEAKER_00: I I was surprised to read it.
• 11:29
  SPEAKER_00: I I'm always a bit envious of my adult colleagues like you who have multiple randomized controlled trials to cite in support of a duration of therapy.
• 11:39
  SPEAKER_00: This is something that in pediatrics has just not existed.
• 11:43
  SPEAKER_00: We're actually quite excited about a study that's now going on where children are randomized between five versus ten days of antibiotics for uncomplicated UTIs.
• 11:54
  SPEAKER_00: And so for the first time, we're hoping we're going to have some actual rigorously done study to guide our future recommendations about duration of therapy.
• 12:04
  SPEAKER_00: And while our the data is not available yet, we're hoping in about two years' time this will this will be uh news for for the rest of the pediatric uh providers to hopefully begin to change the practice with.
• 12:18
  SPEAKER_00: We're optimistic that perhaps five days of therapy will be sufficient.
• 12:22
  SPEAKER_02: Let me ask you about the role that family members play in providers' decisions to initiate antibiotics.
• 12:33
  SPEAKER_02: I know that we encounter this issue in nursing homes quite a bit, and I suspect that you do have some of the same issues in the pediatric population.
• 12:44
  SPEAKER_00: We definitely have a lot of conversations with the parents of young children who are potentially infected with the UTI or something else.
• 12:54
  SPEAKER_00: It's interesting to note, however, over the past 10 years, the actual focus of the conversation is somewhat different.
• 13:01
  SPEAKER_00: In the past, I think many parents would be quicker to say they're anxious because their child has a fever that's unexplained.
• 13:11
  SPEAKER_00: And if there's any chance they might have a bacterial urinary tract infection, let's go ahead and treat it.
• 13:18
  SPEAKER_00: Nowadays, I think there's an increasing proportion of families that might begin a conversation such as what would happen if we waited and saw if this was a true urinary tract infection.
• 13:33
  SPEAKER_00: I'm concerned about unnecessary antibiotic exposure and developing resistance.
• 13:39
  SPEAKER_00: And as pediatricians, those are pretty different conversations to respond to.
• 14:52
  SPEAKER_02: Yeah, I think it raises an issue, and at least in the nursing home population, perhaps a path forward to making some progress, which you kind of highlight is pre-visit education in the nursing home at the time of admission to the nursing home, focusing on educational materials and detailing messages to family members and patients, probably is where you're going to have your biggest bang for your buck.
• 15:24
  SPEAKER_02: What do you think we need to be doing as far as education of clinicians?
• 15:30
  SPEAKER_02: While education is often one of the weakest behavior change interventions, it's still a foundational activity.
• 15:39
  SPEAKER_02: So when you kind of look at your pediatric field, what things do we need to be doing differently as far as educating our colleagues?
• 15:47
  SPEAKER_00: One thing I think is really useful is providing as many specific examples or as much specific data as possible.
• 15:57
  SPEAKER_00: I think oftentimes our guidelines and our recommendations as experts are perceived as too vague to be clearly implemented in specific patients.
• 16:10
  SPEAKER_00: So I'm increasingly taken with kind of case-based teaching around these issues, trying to move away from don't treat things that aren't UTIs, to talking about the truly ambiguous situations that clinicians encounter frequently.
• 16:26
  SPEAKER_00: Specific scenario-based teaching is one way I find myself being more successful.
• 16:32
  SPEAKER_00: And then the other is using data and sharing with people information about how they in fact are practicing and linking that with teaching.
• 16:42
  SPEAKER_02: I couldn't agree with you more that case-based education, particularly focused on these ambiguous presentations, is probably where you're going to have the most influence on provider behaviors.
• 16:55
  SPEAKER_02: So I think when you kind of look at other strategies that facilities and organizations should be focusing on beyond education, we've already touched on this uh a little bit with laboratory protocols.
• 17:10
  SPEAKER_02: I think, you know, decision support tools that delay testing, particularly in ambiguous situations, and perhaps provide just in time education about the diagnostic accuracy of different components of the urinalysis and urine culture can be helpful.
• 17:32
  SPEAKER_02: What do you think about this idea of feedback to providers on their testing and treatment rates for UTI?
• 17:43
  SPEAKER_02: Do you think that there's any value there?
• 17:46
  SPEAKER_00: You know, I really do.
• 17:48
  SPEAKER_00: I have grown to like feedback of data to be a more powerful intervention than some kind of traditional education.
• 17:57
  SPEAKER_00: I think that we all are overly optimistic when we assess our own practice relative to what happens versus what we would like to be doing.
• 18:08
  SPEAKER_00: And I'm sure, in fact, I know there are scenarios in which I would guess my practice is a tad more in accordance with guidelines than it actually is.
• 18:19
  SPEAKER_00: So I think that sort of opportunity to give data back about the use of diagnostics and decision making, as well as the specifics of treatment regimens, you know, duration, dose, agent used, all can be useful.
• 18:35
  SPEAKER_00: It takes time and effort, though, both to generate those reports as well as to guide providers' understanding of what they're seeing and how to use that information.
• 18:45
  SPEAKER_00: So it sometimes is a little more complex than we'd like to think.
• 18:50
  SPEAKER_02: I agree.
• 18:51
  SPEAKER_02: I agree with you on both points.
• 18:53
  SPEAKER_02: I think that it's pretty clear that feedback is probably one of our most effective behavior change tools in our toolkit.
• 19:02
  SPEAKER_02: So I think this discussion that we need more studies on whether feedback is effective is probably not worth the effort.
• 19:11
  SPEAKER_02: Where I think we need to be putting a lot of our effort, and you alluded to this, is uh what type of feedback, both in format and frequency, and whether it's individualized or group.
• 19:22
  SPEAKER_02: I think there's just a lot of additional research that we need in how to tailor feedback to have the maximal impact uh on behavior, and and I really hope that that we see more work uh in that area uh in the future.
• 19:37
  SPEAKER_00: Yeah, no, I I would agree 100%.
• 19:39
  SPEAKER_00: And it's it's exciting to think all the potential areas on beyond just overuse of antibiotics for UTIs that this sort of a system can have.
• 19:49
  SPEAKER_00: But I think for this problem, given how frequently UTIs are treated, both in children and adults, it could be a very important part of improving antibiotic use.
• 20:00
  SPEAKER_00: Another area that we use, at least in hospital-based practice, is suppressing antibiotic resistance results for some of our kind of broader spectrum agents.
• 20:12
  SPEAKER_00: And I don't know if that's something which is done more commonly by perhaps commercial labs that are being used for outpatient providers, but I wonder if there's an opportunity there to promote the prescription of more narrow spectrum agents.
• 20:28
  SPEAKER_02: I think you're you're right, and that's an area where I think we need to do some actual studies to show that convincingly.
• 20:37
  SPEAKER_02: Obviously, we do the same thing in our hospitals.
• 20:40
  SPEAKER_02: Um, and and I think you're absolutely right that those those sorts of things do have an impact.
• 20:47
  SPEAKER_02: That data does influence prescribing decisions both in the wrong direction as as well as hopefully the the right direction, but I think we need more research on on how to frame that that information.
• 20:59
  SPEAKER_02: Right.
• 21:01
  SPEAKER_02: Well, I think we're in in agreement that we need more uh and higher quality studies looking at uh behavioral change interventions, including how to frame feedback to providers, how to structure test results in a way that that facilitates better decision making.
• 21:24
  SPEAKER_02: Where do you see this playing out in, you know, given that the ambulatory setting is is just a much different animal from the hospital setting?
• 21:35
  SPEAKER_00: I I would definitely agree.
• 21:37
  SPEAKER_00: You know, because pediatrics has been behind, I hope for the greatest impact would be evidence that we can use a course as short as five days to treat.
• 21:47
  SPEAKER_00: But I do like the idea of trying to explore different options for regularizing or ensuring that these antibiotic timeouts occur in outpatient settings as well.
• 22:01
  SPEAKER_00: I know of a few academic practices that have nursing staff call patients with changes in antibiotic prescriptions based on the urine culture results, but I don't think this is the norm.
• 22:14
  SPEAKER_00: And I've heard some discussion of more creative prescribing where a two-tier prescription is written, one for two days of therapy, and then the second for an additional week of therapy is essentially a refill upon direction by the prescriber.
• 22:30
  SPEAKER_00: While those are somewhat clunky for families, I don't think families would necessarily be very excited about going to the pharmacy twice in two or three days.
• 22:39
  SPEAKER_00: Perhaps with better understanding of what there is potentially to gain by limiting antibiotic exposure, we'll have more willingness of families to at least try some of these more creative strategies.
• 22:53
  SPEAKER_02: Sounds like we've got quite the research agenda in front of us.
• 22:57
  SPEAKER_00: Well, we better get cracking on it.
• 23:02
  SPEAKER_01: Looking to extend your knowledge in antibiotic stewardship and infection prevention?
• 23:07
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• 23:10
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• 23:23
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• 23:29
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