ER utilization and overtreatment for UTI in pediatric patients with spina bifida

In this interview, Briony K. Varda, MD, MPH, discusses 2 studies related to the treatment of urinary tract infection (UTI) among pediatric patients with spina bifida, for which she served as the senior author. Varda is a pediatric urologist, the co-director of the spina bifida program, and the director of clinical research at Children’s National Hospital in Washington, DC.

Briony K. Varda, MD, MPH

This transcription has been edited for clarity.

I want to start with the study, “Getting to the bottom of why children with spina bifida use the emergency department: A qualitative analysis of parent and stakeholder perspectives.” Could you highlight the background and rationale for this study?

We knew from prior research, as well as our own institutional research, that emergency department use by children with spinal bifida was more frequent than the general pediatric population. We wanted to know, from the patient and family perspective, why they might choose to use the emergency room rather than another health care resource.

What were the key findings?

This was a qualitative research study where we interviewed 16 families. A portion of the families were Spanish speaking, and the interviews were conducted in Spanish. Then, we used the data or the transcripts from the interviews to analyze these reasons for emergency department use. We ended up finding 6 themes. The first theme—and probably the most common theme, the theme that seemed to really have the most meaning for everybody—was that the emergency room provided, "a 1-stop shop," type of experience, meaning they were able to get everything they needed in one go. So, they were able to see subspecialists, they were able to get any kind of imaging they needed, any kind of lab work, and they had interpreters available. In many ways, this was much easier for families to do than to try to coordinate several different outpatient visits, even if the problem didn't necessarily meet the level of an emergency, so to speak.

We also had 5 other themes that we identified. The second theme that popped up was, I think, predictable, which was basically that the family felt that their child had an emergency and needed to come to the emergency room. Within those discussions, the most frequent concerns included urinary tract infection and shunt problems. Beyond that theme, we also had a theme that related to negative past experiences. So, these families, when they tried to use the pediatrician or they tried to use urgent care, what they found was that the complete care couldn't be performed; either they lacked equipment, or they lacked knowledge of what needed to be involved in the workup. They just have naturally chosen to bypass those situations.

The other themes involved just coming to the emergency room because that had been the recommendation from a provider. So, either they called, and we told them, “yes, you need to come in,” or their pediatrician told them “yes, you need to go.” Or, we had counseled them in the past that you need to come to the emergency room for a certain thing, and so they did that. The last 2 themes that we hit on, one had to do with the patient's intrinsic emotions and feelings about what was happening; so, whether they felt that they were competent and caring for their child's problem. Were they anxious? Were they paranoid? Were they overly concerned and emotionally connected to that concern? Or did they feel burned out? That seemed to moderate some of the other themes. In particular, we saw that parents of young children or infants who are less familiar with the condition and taking care of children were more apt to feel out of their depths and come to the emergency room. Then finally, the last thing was, again, very predictable. Patients use the emergency room on the weekends and at times where they were not able to access outpatient care.

What are some key takeaways for pediatric urologists?

It's really important, and this isn't necessarily new. I think this underscores the importance of coordinated care being available to these patients. At our institution, we do have a nurse coordinator, an NP––who helps in particular with bowel management––and we have a multidisciplinary clinic. But even so, it still can be challenging for families to get through and get the advice that they need. One thing that we've leveraged is a dedicated email and a dedicated phone number so that we're available to answer calls to families whenever something may come up. We also provide a lot of educational materials now in our communications with pediatricians and community providers, so that the knee-jerk [reaction] isn't to send our children to the emergency room necessarily.

Then I would say, finally, we've done a lot of work focusing in on one of the problems that comes up a lot, which is urinary tract infections. We know that our patients who self-catheterize tend to look like they have a urinary tract infection when you do the standard testing like a urinalysis and a culture, but that doesn't always mean that they need to be treated. We've been working with families and other providers to learn the diagnostic criteria for what makes a urinary tract infection and to avoid treating when it's unnecessary.

That leads into the next abstract, “Antibiotic Overtreatment of Presumed Urinary Tract Infection Among Children with Spina Bifida.” Could you highlight the background and key findings from that study?

This was a really an interesting study. We wanted to know for our spina bifida patients that presented to the emergency room, how many of them were treated for a urinary tract infection when they didn't meet diagnostic criteria for a urinary tract infection. This is based on the idea that there are different criteria for a UTI in patients who self-catheterize. Specifically, these patients need to have 2 or more urologic symptoms, they need to have more than 10 white blood cells in their urinalysis, and they need to have a urine culture that grows greater than 100,000 of a single bacteria. In many instances, our patients were being treated and not meeting all 3 criteria. So, we looked at the rate of that occurrence.

In short, 80% of our patients who received antibiotics were over-treated. What we found was that pyuria, or the incidence of white blood cells in the urinalysis, was a big driver for treating patients with antibiotics. But many of those patients would end up having negative cultures later, or they wouldn't have symptoms and were treated simply for the white blood cells in the urine. So, that was an important finding. Then the second aspect of this is that we found that patients who were non-White were more likely to be overtreated, which made us concerned about the thoroughness of symptom elicitation and just relying on testing rather than connecting with the patient and understanding their concerns. We also found that headache was not associated with a UTI. In some patient populations, such as in the spinal cord population, it can be associated. But it's important to note that our spina bifida patients are different and headache really wasn't a predictor of a true UTI. So, overall, our patients were over-treated at a very high rate, and certain patients were over-treated in comparison to others.

What are the main take-home points for urologists?

The thing that was glaring to me is that patient symptoms should be the first and most important thing that we use to determine whether or not we treat our patients with spina bifida for a urinary tract infection. The testing just is not good enough yet to distinguish what's a true infection vs what represents chronic abacterial cystitis or bacterial colonization. So, my big take-home was to lean into symptoms. I think in terms of symptom elicitation, it's important to be systematic so that we don't shortchange certain populations when we try to figure out what their symptoms are.

What are some future directions for research based on this study?

We're in dire need of a better diagnostic tool for urinary tract infections. We did a separate study using the same data and found that no matter what threshold of white blood cells you use for the urine, it was no better at predicting true UTI. I hope and know that many people are working in the lab to try to develop better tests. I would continue to encourage that. And then I would [encourage others to] work with [their] institutional, emergency room, hospitalist, etc, on antibiotic stewardship to ensure that this patient population isn't getting over treated and developing antibiotic resistance.

Is there anything else that you’d like to add?

It's been a pleasure to have this multidisciplinary team that I work with at Children's National. We're fortunate to be able to follow up on these presentations quickly, and to try to figure out what's going on. So, I just thank them for all their hard work here at our hospital.