Kenneth B. Roberts

Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months

OBJECTIVE: To revise the American Academy of Pediatrics practice parameter regarding the diagnosis and management of initial urinary tract infections (UTIs) in febrile infants and young children. METHODS: Analysis of the medical literature published since the last version of the guideline was supplemented by analysis of data provided by authors of recent publications. The strength of evidence supporting each recommendation and the strength of the recommendation were assessed and graded. RESULTS: Diagnosis is made on the basis of the presence of both pyuria and at least 50 000 colonies per mL of a single uropathogenic organism in an appropriately collected specimen of urine. After 7 to 14 days of antimicrobial treatment, close clinical follow-up monitoring should be maintained to permit prompt diagnosis and treatment of recurrent infections. Ultrasonography of the kidneys and bladder should be performed to detect anatomic abnormalities. Data from the most recent 6 studies do not support the use of antimicrobial prophylaxis to prevent febrile recurrent UTI in infants without vesicoureteral reflux (VUR) or with grade I to IV VUR. Therefore, a voiding cystourethrography (VCUG) is not recommended routinely after the first UTI; VCUG is indicated if renal and bladder ultrasonography reveals hydronephrosis, scarring, or other findings that would suggest either high-grade VUR or obstructive uropathy and in other atypical or complex clinical circumstances. VCUG should also be performed if there is a recurrence of a febrile UTI. The recommendations in this guideline do not indicate an exclusive course of treatment or serve as a standard of care; variations may be appropriate. Recommendations about antimicrobial prophylaxis and implications for performance of VCUG are based on currently available evidence. As with all American Academy of Pediatrics clinical guidelines, the recommendations will be reviewed routinely and incorporate new evidence, such as data from the Randomized Intervention for Children With Vesicoureteral Reflux (RIVUR) study. CONCLUSIONS: Changes in this revision include criteria for the diagnosis of UTI and recommendations for imaging.

Urinary tract infection in infants with unexplained fever: a collaborative study.

Nine centers collaborated to determine the rate of urinary tract infection in infants with unexplained fever, to determine whether the rate is higher in febrile infants than in asymptomatic infants, and whether the yield justifies urine cultures in febrile infants. Urine cultures were done in 501 infants 0 to 2 years of age. The rate of confirmed urinary tract infections in the 193 febrile infants was 4.1%. All infections were in girls, with a rate of 7.4%. The rate of confirmed urinary tract infections in the 312 asymptomatic infants was 0.3%; again, all infections were in girls, with a rate of 0.7%. The rate in febrile girls was significantly higher than the rate in asymptomatic girls (P less than 0.01). The data support the advisability of culturing the urine of infant girls with unexplained fever.

Preparing Future Pediatricians: Making Time Count

At the 2011 annual meeting of the Pediatric Academic Societies participants debated whether the duration of pediatric residency should be extended. Those favoring a longer residency argued that there is more to learn now than 30 years ago and, because of regulations curtailing resident work hours, less time in which to learn it. Their opponents argued that the purpose of residency is basic competence, notmastery, and there is still sufficient time and flexibility for residents to achieve basic competence. Moreover, adding time to the residency would be prohibitively expensive. A proposal to extend residency is a simple (and simplistic) solution to complex issues. In addition to the increase in medical knowledge in recent decades, the scope of pediatrics haswidened, and subspecializationhasprogressed; learners’ exposure to various aspects of pediatrics is now occurring, if at all, in distinct andseparate silos. Althoughsetting basic competence, rather than mastery, as the outcome measure may seem reassuring, defining “basic competence” is challenging: does the term refer to a basic level of competence in the vast breadth of pediatrics or to competence in a narrow basic “core” of pediatrics? This is a fundamental distinction for educators, future pediatricians, and the public, and there are implications for length of medical school and residency training and breadth of experiences required or necessary during training. The Association of American Medical Colleges is undertaking a pediatrics redesign project for students interested in pediatrics that begins in the second year of medical school and progresses to the end of residency.1 Transition frommedical school to residency and residency to practice will be based on competence rather than time. Thiseffort isanexciting opportunity to create a true continuum of learning, but the results of the project will not beknown forquite awhile and, in the short-term, will only involve a small number of students. In the meantime, the vast majority of future pediatricians, and their teachers, face the daunting task of ensuring adequate preparation for residency after completion of medical school and readiness for unsupervised practice after completion of residency in the current system. One approach to enhancing the likelihood that future pediatricians are broadly competent is to better use opportunities available in the fourth year of medical school.

Infectious Mononucleosis in Adolescents

Infectious mononucleosis is a clinical manifestation of primary EBV infection in adolescents, characterized by a triad of clinical, laboratory, and serologic features. The classic signs and symptoms are not seen in every patient; rather, the presentations tend to fit into one of three clinical forms (pharyngeal, glandular, or febrile). Recognizing these syndromes provides a useful framework for anticipating the clinical course, complications, and differential diagnosis. Nonclassic presentations of IM include a wide variety of neurologic abnormalities, thrombocytopenic purpura, and splenic rupture. The laboratory features of IM include absolute lymphocytosis with a large percentage of atypical lymphocytes, and abnormal liver chemistries in 90% of patients. The diagnosis of IM is confirmed serologically, usually with the demonstration of heterophile antibodies; the test can conveniently be performed in office laboratories. If the heterophile antibody test is negative, EBV-specific serologic tests can identify whether the illness is due to primary EBV infection. Once the diagnosis of IM is made, appropriate guidelines for resumption of activity should be provided to patients, especially to those with evidence of splenomegaly. Medical management includes supportive therapy with adequate analgesia. Corticosteroids are indicated for patients with upper airway obstruction; they may be helpful in patients with neurologic, hematologic, or cardiac complications. Acyclovir may prove to be useful, but further studies are needed before its use can be recommended.

The epidemiology and clinical presentation of urinary tract infections in children younger than 2 years of age.

UTI in young infants generally presents with fever. Among the youngest infants, boys and girls are equally affected. The incidence of UTI in uncircumcised boys is comparable with that in girls, whereas the rate in circumcised boys is much lower. Based on gender and race, white girls have the highest incidence of UTI. A full understanding of the epidemiology of UTI is complicated by the presence of asymptomatic bacteriuria and by incomplete evidence regarding the significance of scarring and the risk of sequelae.

Resident Preparedness for Practice: A Longitudinal Cohort Study

OBJECTIVE To determine whether the perception of preparedness for practice changes over time. DESIGN Questionnaire survey of University of Massachusetts residents 5 years after an initial survey. Responses to individual questions in the 2 surveys were compared for each graduate and the Wilcoxon rank sum test applied. A supplementary questionnaire addressed current confidence in areas with relatively low scores in both surveys. RESULTS All 24 eligible graduates responded. The high rating of overall sense of preparedness was identical in the 2 surveys. Differences were statistically significant in only 3 categories: common illnesses, office gastroenterology, and office gynecology-all from a lower estimate of preparedness initially to a higher estimate in retrospect. Six areas continued to receive relatively low scores: nutrition, patient scheduling, cost-effectiveness, telephone management, office gynecology, and office orthopedics. Respondents feel more confident currently with nutrition, patient scheduling, and telephone management but not with cost-effectiveness, gynecology, or orthopedics. CONCLUSIONS Residents paired with office-based practitioners for their continuity experience report feeling well prepared for practice both on practice entry and 5 to 9 years later. In the 6 areas of relatively low preparedness, experience improved confidence with nutrition, patient scheduling, and telephone management, but not cost-effectiveness, gynecology, or orthopedics. The hypothesis that clinical areas of relative weakness at the end of residency may remain so years later deserves to be tested.

The APA/HRSA Faculty Development Scholars Program: Introduction to the Supplement

BACKGROUND The purpose of this project was to improve pediatric primary care medical education by providing faculty development for full-time and community-based faculty who teach general pediatrics to medical students and/or residents in ambulatory pediatric community-based settings. Funding for the program came through an interagency agreement with the Health Resources and Services Administration (HRSA) and the Agency for Healthcare Research and Quality (AHRQ). METHODS A train-the-trainer model was used to train 112 scholars who could teach skills to general pediatric faculty across the nation. The three scholar groups focused on community-based ambulatory teaching; educational scholarship; and executive leadership. RESULTS Scholars felt well prepared to deliver faculty development programs in their home institutions and regions. They presented 599 workshops to 7989 participants during the course of the contract. More than 50% of scholars assumed positions of leadership, and most reported increased support for medical education in their local and regional environments. CONCLUSIONS This national pediatric faculty development program pioneered in the development of a new training model and should guide training of new scholars and advanced and continuing training for those who complete a basic program.

Response to the AAP Section on Urology Concerns About the AAP Urinary Tract Infection Guideline

* Abbreviations: AAP — : American Academy of Pediatrics CKD — : chronic kidney disease SOU — : Section on Urology UTI — : urinary tract infection VCUG — : voiding cystourethrogram The American Academy of Pediatrics (AAP) Section on Urology (SOU)1 raises several concerns regarding the new AAP Urinary Tract Infection (UTI) Clinical Practice Guideline.2 The SOU takes issue with the 6 randomized controlled trials that assess the effectiveness of prophylaxis.3–8 Specifically, the SOU draws attention to the use of bag specimens; the lack of information about circumcision, elimination habits, and compliance; and the small number of subjects in the individual studies. Address correspondence to Kenneth B. Roberts, MD, 3005 Bramblewood Dr, Mebane, NC 27302. E-mail: kenrobertsmd{at}gmail.com

The Diagnosis of UTI: Liquid Gold and the Problem of Gold Standards

Why is urine yellow? Because it is liquid gold! Pediatric nephrologist William Primack* For >50 years, the gold standard for the diagnosis of urinary tract infections (UTIs) has been a positive culture result without regard for urinalysis findings. Both the definition of “positive” and the role of urinalysis stem from a publication in 1956.1 Edward Kass applied quantitative culture methods to urine specimens obtained from adults by catheterization to determine a dividing line between contamination and infection. The urine of most, but not all, patients with symptoms of acute pyelonephritis (chills, fever, flank pain, and dysuria) contained >100 000 CFU/mL. Urine specimens from some asymptomatic women also had such high colony counts but most were much lower. Kass concluded: “For survey purposes, a count of 105 bacteria or more per mL of urine has been designated arbitrarily as the dividing line between true bacilluria and contamination.” He acknowledged that for “individual clinical purposes,” lower colony counts needed to be considered and noted that pyuria did not reliably accompany bacteriuria in the asymptomatic women. During the subsequent decade, screening programs were widely conducted, applying ≥10 … Address correspondence to Kenneth B. Roberts, MD, 3005 Bramblewood Dr, Mebane, NC 27302. E-mail: kenrobertsmd{at}gmail.com

Institutions and Individuals: What Makes A Hospitalist “Academic”?

As pediatric hospital medicine (PHM) develops and matures, attempts have been made to describe the field and the individuals who practice it.1–3 Defining what PHM practitioners do is complex, and descriptive categories are often presented with dichotomous alternatives regarding responsibilities (eg, teaching or not, research/scholarly activity or not) and scope of practice (eg, limited to inpatient service or broader, full array of resources or not). Frequently, the differences are overly simplified according to the type of institution in which the pediatric hospitalists work, labeled “academic centers” and “community hospitals.”1,3,4 However, the designation of 1 setting as “academic” implies that the alternative (community hospitals) is not academic, a distinction that spills over to labeling individual hospitalists as academic or nonacademic. According to Freed and Dunham,1 academic hospitalists are those with a full-time faculty appointment, whereas hospitalists with a part-time or no faculty appointment are considered nonacademic. Appointments are conferred by universities, however, so this definition of academic largely reverts to the type of institution in which the pediatric hospitalist works rather than the type of work the pediatric hospitalist does. We propose that the alternative to community hospitals is better described as “university/children’s hospitals” than academic centers because hospitalists may perform …