[Show abstract][Hide abstract] ABSTRACT: Purpose
Prior single center studies showed that antibiotic resistance patterns differ between outpatients and inpatients. We compared antibiotic resistance patterns for urinary tract infection between outpatients and inpatients on a national level.
Materials and Methods
We examined outpatient and inpatient urinary isolates from children younger than 18 years using The Surveillance Network (Eurofins Scientific, Luxembourg, Luxembourg), a database of antibiotic susceptibility results, as well as patient demographic data from 195 American hospitals. We determined the prevalence and antibiotic resistance patterns of the 6 most common uropathogens, including Escherichia coli, Proteus mirabilis, Klebsiella, Enterobacter, Pseudomonas aeruginosa and Enterococcus. We compared differences in uropathogen prevalence and resistance patterns for outpatient and inpatient isolates using chi-square analysis.
We identified 25,418 outpatient (86% female) and 5,560 inpatient (63% female) urinary isolates. Escherichia coli was the most common uropathogen overall but its prevalence varied by gender and visit setting, that is 79% of uropathogens overall for outpatient isolates, including 83% of females and 50% of males, compared to 54% for overall inpatient isolates, including 64% of females and 37% of males (p <0.001). Uropathogen resistance to many antibiotics was lower in the outpatient vs inpatient setting, including trimethoprim/sulfamethoxazole 24% vs 30% and cephalothin 16% vs 22% for E. coli (each p <0.001), cephalothin 7% vs 14% for Klebsiella (p = 0.03), ceftriaxone 12% vs 24% and ceftazidime 15% vs 33% for Enterobacter (each p <0.001), and ampicillin 3% vs 13% and ciprofloxacin 5% vs 12% for Enterococcus (each p <0.001).
Uropathogen resistance rates of several antibiotics are higher for urinary specimens obtained from inpatients vs outpatients. Separate outpatient vs inpatient based antibiograms can aid in empirical prescribing for pediatric urinary tract infections.
The Journal of urology 05/2014; 189(4). DOI:10.1016/j.juro.2013.10.064 · 4.47 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Antibiotics are a mainstay in the treatment of bacterial infections, though their use is a primary risk factor for the development of antibiotic resistance. Antibiotic resistance is a growing problem in pediatric urology as demonstrated by increased uropathogen resistance. Lack of urine testing, nonselective use of prophylaxis, and poor empiric prescribing practices exacerbate this problem. This article reviews antibiotic utilization in pediatric urology with emphasis on modifiable practice patterns to potentially help mitigate the growing rates of antibiotic resistance. This includes urine testing to only treat when indicated and tailor broad-spectrum therapy as able; selective application of antibiotic prophylaxis to patients with high-grade vesicoureteral reflux and hydronephrosis with counseling regarding the importance of compliance; and using local antiobiograms, particularly pediatric-specific antiobiograms, with inpatient versus outpatient data.
Therapeutic Advances in Urology 04/2014; 6(2):54-61. DOI:10.1177/1756287213511508
[Show abstract][Hide abstract] ABSTRACT: Objective
Augmentation cystoplasty (AC) is a major surgery that can be associated with long-term morbidity. This study aimed to describe the cumulative incidence of outcomes and urologic procedures in a large cohort of children who underwent AC, identify significant sources of morbidity, and to evaluate baseline factors associated with outcomes of interest.
Children ≤18 years who underwent AC in the Pediatric Health Information System from 1999 to 2010 were included. All follow-up encounters up to June 2012 were included. Cumulative incidences for 15 outcomes and urologic procedures were calculated using non-informative censoring. Sensitivity analyses were performed to determine effect of censoring assumptions and including hospitals without complete datasets. As an exploratory analysis, baseline patient factors were evaluated for associations with outcomes and urologic procedures of interest using multivariable Cox proportional hazards models adjusted for clustering by hospital.
2831 AC patients were identified. Based on cumulative incidence calculations and sensitivity analyses; the cumulative incidence ranges of outcomes and procedures at 1, 3, 5, and 10 years were calculated. Examples of 10-year cumulative incidence ranges are given for the following outcomes and procedures: bladder rupture (2.9–6.4%), small bowel obstruction (5.2–10.3%), bladder stones (13.3–36.0%), pyelonephritis (16.1–37.1%), cystolithopaxy (13.3–35.1%), and reaugmentation (5.2–13.4%). The development of chronic kidney disease was strongly associated with a diagnosis of lower urinary tract obstruction (HR 13.7; 95% CI 9.4–19.9). Bladder neck surgery and stoma creation at time of AC were associated with an increased hazard of bladder rupture (HR 1.9; 95% CI 1.1–3.3) and bladder stones (HR 1.4; 95% CI 1.1–1.8) respectively.
Outcomes of interest and urologic procedures after AC are common. Results from this large cohort can be used to counsel patients and families about expectations after AC. Pyelonephritis, chronic kidney disease, further reconstructive surgery, and calculus disease appear to cause significant morbidity. Collaborative efforts are needed to further reduce morbidity in this patient population.
[Show abstract][Hide abstract] ABSTRACT: Objective
Hypospadias is usually treated in childhood. Therefore, the natural history of untreated mild hypospadias is unknown. We hypothesized that men with untreated hypospadias, especially mild, do not have adverse outcomes.
Facebook was used to advertise an electronic survey to men older than 18 years. Men with untreated hypospadias identified themselves and indicated the severity of hypospadias with a series of questions. Outcomes included: Sexual Health Inventory for Men (SHIM), penile curvature and difficulty with intercourse, International Prostate Symptom Score (IPSS), Penile Perception Score (PPS), psychosexual milestones, paternity, infertility, sitting to urinate, and the CDC HRQOL-4 module.
736 men completed self-anatomy questions and 52 (7.1%) self-identified with untreated hypospadias. Untreated hypospadias participants reported worse SHIM (p<0.001) and IPSS scores (p=0.05), more ventral penile curvature (p=0.003) and resulting difficulty with intercourse (p<0.001), worse satisfaction with meatus (p=0.011) and penile curvature (p=0.048), and more sitting to urinate (p=0.07). When stratified by mild and severe hypospadias, severe hypospadias was associated with more adverse outcomes than mild hypospadias.
Men with untreated hypospadias reported worse outcomes compared with non-hypospadiac men. Mild untreated hypospadias had fewer adverse outcomes than severe hypospadias. Research is needed to determine if treatment of childhood hypospadias improves outcomes in adults, especially for mild hypospadias.
[Show abstract][Hide abstract] ABSTRACT: Secondary data analysis is the use of data collected by someone other than the investigator for research. In the last several years there has been a dramatic increase in the number of these studies being published in urologic journals and presented at urologic meetings, especially of secondary data analysis of large administrative datasets. Along with this expansion, skepticism for secondary data analysis studies has increased for many urologists.
In this narrative review we discuss the types of large datasets that are commonly used for secondary data analysis in urology and discuss the advantages and disadvantages of secondary data analysis. A literature search was performed to identify urologic secondary data analysis studies published since 2008 using commonly used large datasets and examples of high quality studies published in high impact journals are given. We outline an approach for performing a successful hypothesis or goal driven secondary data analysis study and highlight common errors to avoid.
Over 350 secondary data analysis studies using large datasets have been published on urologic topics since 2008 with likely many more studies presented at meetings but never published. Non-hypothesis or goal driven studies have likely constituted some of these studies and have probably contributed to increased skepticism of this type of research. However, many high quality hypothesis driven studies addressing research questions that would have been difficult to study with other methods have been performed in the last few years.
Secondary data analysis is a very powerful tool that can address questions which could not be adequately studied by another method. Knowledge of limitations of secondary data analysis and of the datasets used is critical for a successful study. There are also important errors to avoid when planning and performing a secondary data analysis study. Investigators and the urologic community need to strive to use secondary data analysis of large datasets appropriately to produce high quality studies that hopefully lead to improved patient outcomes.
The Journal of urology 10/2013; 191(3). DOI:10.1016/j.juro.2013.09.091 · 4.47 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective:
To characterize urine test use in ambulatory, antibiotic-treated pediatric urinary tract infection (UTI).
We studied children <18 years who had an outpatient UTI and a temporally associated antibiotic prescription from 2002 through 2007 by using a large claims database, Innovus i3. We evaluated urine-testing trends and performed multivariable logistic regression to assess for factors associated with urine culture use.
Of 40 603 treated UTI episodes in 28 678 children, urinalysis was performed in 76%, and urine culture in 57%; 32% of children <2 years had no urinalysis or culture performed for an antibiotic-treated UTI episode. Urine culture use decreased during the study period from 60% to 54% (P < .001). We observed variation in urine culture use with age (<2 years: odds ratio [OR] 1.0, 95% confidence interval [CI] 0.9-1.1; 2-5 years: OR 1.3, 95% CI 1.2-1.4; 6-12 years: OR 1.3, 95% CI 1.2-1.4, compared with 13-17 years); gender (boys: OR 0.8, 95% CI 0.8-0.9); and specialty (pediatrics: OR 2.6, 95% CI 2.5-2.8; emergency medicine, OR 1.2, 95% CI 1.1-1.3; urology: OR 0.5, 95% CI 0.4-0.6, compared with family/internal medicine). Recent antibiotic exposure (OR 1.1, 95% CI 1.1-1.2) and empirical broad-spectrum prescription (OR 1.2, 95% CI 1.1-1.2) were associated with urine culture use, whereas previous UTI and urologic anomalies were not.
Providers often do not obtain urine tests when prescribing antibiotics for outpatient pediatric UTI. Variation in urine culture use was observed based on age, gender, and physician specialty. Additional research is necessary to determine the implications of empirical antibiotic prescription for pediatric UTI without confirmatory urine testing.
[Show abstract][Hide abstract] ABSTRACT: Objective:
To better understand parental beliefs regarding the etiology and treatment of nocturnal enuresis (NE).
A self-administered survey queried parental NE beliefs including perceived etiologies and home behavioral treatments. We assessed for associations between demographic characteristics and propensity to seek medical care for NE.
Of 216 respondents, 78% were female. The most common causes for NE reported were: deep sleeper (56%), unknown (39%), and laziness (26%). Popular home behavioral therapies included: void prior to sleep (77%) and limiting fluid intake at night (71%). Few reported they would use a bedwetting alarm (6%). Fifty-five percent reported they would seek medical care for NE and 28% reported awareness of effective treatments. On multivariable analysis, females (OR 2.3, 95% CI 1.04-5.0) and those with graduate level education (OR 4.8, 95% CI 1.5-15.7) were more likely to seek medical care for their child with NE.
General parental knowledge of the causes and effective treatments for NE is lacking. Only 55% reported they would seek medical care for their child with NE and only 28% reported awareness of effective treatments. Counseling should focus on dispelling common misconceptions about causes and treatments of NE and focus on proven effective treatments.
[Show abstract][Hide abstract] ABSTRACT: Purpose:
We characterize the current national patterns of antibiotic resistance of outpatient pediatric urinary tract infection.
Materials and methods:
We examined outpatient urinary isolates from patients younger than 18 years in 2009 using The Surveillance Network®, a database with antibiotic susceptibility results and patient demographic data from 195 United States hospitals. We determined the prevalence and antibiotic resistance patterns for the 6 most common uropathogens, ie Escherichia coli, Proteus mirabilis, Klebsiella, Enterobacter, Pseudomonas aeruginosa and Enterococcus. We compared differences in uropathogen prevalence between males and females using chi-square analysis.
We identified 25,418 outpatient urinary isolates. E. coli was the most common uropathogen overall but the prevalence of E. coli was higher among females (83%) than males (50%, p <0.001). Other common species among males were Enterococcus (17%), P. mirabilis (11%) and Klebsiella (10%). However, these uropathogens each accounted for 5% or less of female isolates (p <0.001). Resistance among E. coli was highest for trimethoprim-sulfamethoxazole (24%) but lower for nitrofurantoin (less than 1%) and cephalothin (15%). Compared to 2002 Surveillance Network data, E. coli resistance rates increased for trimethoprim-sulfamethoxazole (from 23% to 31% in males and from 20% to 23% in females) and ciprofloxacin (from 1% to 10% and from 0.6% to 4%, respectively).
E. coli remains the most common pediatric uropathogen. Although widely used, trimethoprim-sulfamethoxazole is a poor empirical choice for pediatric urinary tract infections in many areas due to high resistance rates. First-generation cephalosporins and nitrofurantoin are appropriate narrow-spectrum alternatives given their low resistance rates. Local antibiograms should be used to assist with empirical urinary tract infection treatment.
The Journal of urology 01/2013; 190(1). DOI:10.1016/j.juro.2013.01.069 · 4.47 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To investigate whether orchiopexies are occurring later than recommended by American Academy of Pediatrics 1996 guidelines (around age 1). Adherence to guidelines is poorly studied.
The main cohort consisted of 4103 boys insured from birth (Innovus i3, insurance claims database). The complementary cohort consisted of 17 010 insured and noninsured boys (Pediatric Health Information System, PHIS). The inclusion criteria was age ≤5 years at time of International Classification of Disease, 9th revision-defined cryptorchidism diagnosis. The primary outcome was timely surgery (orchiopexy by age 18 months).
In Innovus, 87% of boys who underwent an orchiopexy had a timely orchiopexy. Of those who did not undergo surgery (n = 2738), 90% had at least 1 subsequent well-care visit. Those who underwent timely surgery were referred to a surgeon at a younger age compared with those who underwent late surgery (4.1 vs 16.1 months, P < .00005). Predictors of timely surgery were number of well-care visits (odds ratio 1.5, 95% confidence interval 1.3-1.7), continuity of primary care (odds ratio 1.9, 95% confidence interval 1.3-2.7), and use of laparoscopy (odds ratio 4.5, 95% confidence interval 1.4-14.9). Family/internal medicine as referring provider was predictive of delayed surgery (odds ratio 0.5, 95% confidence interval 0.3-0.8). In the Pediatric Health Information System, 61% of those with private insurance had timely surgery compared with 54% of those without private insurance (P < .0001).
We found an unexpectedly high adherence to guidelines in our continuously insured since birth Innovus population. Primary care continuity and well-care visits were associated with timely surgery. Further studies can confirm these findings in nonprivately insured patients with the ultimate goal of instituting quality improvement initiatives.
[Show abstract][Hide abstract] ABSTRACT: Cryptorchidism (undescended testis) is the most common genitourinary anomaly in male infants.
We reviewed the available literature on the diagnostic performance of ultrasound, computed tomography, and magnetic resonance imaging (MRI) in localizing undescended testes.
Ultrasound is the most heavily used imaging modality to evaluate undescended testes. Ultrasound has variable ability to detect palpable testes and has an estimated sensitivity and specificity of 45% and 78%, respectively, to accurately localize nonpalpable testes. Given the poor ability to localize nonpalpable testes, ultrasound has no role in the routine evaluation of boys with cryptorchidism. Magnetic resonance imaging has greater sensitivity and specificity but is expensive, not universally available, and often requires sedation for effective studies of pediatric patients. Diagnostic laparoscopy has nearly 100% sensitivity and specificity for localizing nonpalpable testes and allows for concurrent surgical correction.
Although diagnostic imaging does not have a role in the routine evaluation of boys with cryptorchidism, there are clinical scenarios in which imaging is necessary. Children with ambiguous genitalia or hypospadias and undescended testes should have ultrasound evaluation to detect the presence of müllerian structures.
Journal of Pediatric Surgery 12/2011; 46(12):2406-13. DOI:10.1016/j.jpedsurg.2011.08.008 · 1.39 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We examined trends in pediatric hospitalization for pyelonephritis from 1985 to 2006 and identified factors associated with admission.
We performed a population based analysis of hospital discharges using the Office of Statewide Health Planning and Development database to evaluate trends in California regarding pediatric hospitalizations for pyelonephritis from 1985 to 2006. Multivariable logistic regression was performed to identify factors associated with admission for pyelonephritis.
A total of 46,300 children were hospitalized for pyelonephritis in California from 1985 to 2006. The overall rate of hospitalization for pyelonephritis increased by greater than 80%, from 17 per 100,000 children in the California population in 1985 to 31 per 100,000 in 2005. This change was primarily due to the nearly ninefold increase in pyelonephritis hospitalizations observed in children younger than 1 year, from 28 per 100,000 in 1985 to 238 per 100,000 in 2005. Among children younger than 1 year males without private insurance and of nonwhite race had increased odds of hospitalization, while females with private insurance and of Asian race had increased odds of hospitalization, compared with nonprivate insurance and white race, respectively.
A significant increase in hospital admissions for pyelonephritis, primarily in children younger than 1 year, occurred in California between 1985 and 2006. Further studies are needed to establish the cause of this striking increase and to determine why certain pediatric populations are at increased risk for hospitalization.
The Journal of urology 09/2011; 186(3):1028-34. DOI:10.1016/j.juro.2011.04.101 · 4.47 Impact Factor