Acute health care utilization and outcomes for outpatient-treated urinary tract infections in children.

INTRODUCTION: The majority of urinary tract infections (UTIs) in children are treated in the ambulatory setting. The goal of this study is to describe the course of outpatient UTI management, including health services utilization, antibiotic switching (change from empirically prescribed antibiotic to another antibiotic), and antibiotic side effects. METHODS: Using a large claims database, Truven Health MarketScan Research Database, we analyzed all children younger than 18 years old who had an antibiotic prescribed for an outpatient UTI from 2002 to 2010. We evaluated health services utilization and antibiotic switching in the 21-day period after UTI diagnosis. We compared side effects with rates in patients receiving narrow versus broad-spectrum antibiotic treatment. Chi-square analysis was used for descriptive statistics. RESULTS: We identified 242,819 outpatient, antibiotic-treated, UTI episodes. During the 21-day period after presentation, 26% required more than one visit for UTI management and <1% required hospital admission (Figure). Most children did not have imaging within 21 days of UTI: renal bladder ultrasound in 6%, VCUG in 2.6%, and DMSA in 0.05%. Broad-spectrum antibiotics were empirically prescribed to 34% of patients. Antibiotic switching occurred in only 8% of UTI episodes, indicating that empiric prescription covered the offending uropathogen the majority of the time. Antibiotic side effects occurred in 8% of UTI episodes. The most common side effects were gastrointestinal (∼3% of UTI episodes). All other side effects occurred in <1% of UTI episodes. Although there were statistically significant differences in side effects between broad- and narrow-spectrum antibiotics, these differences were not clinically relevant. CONCLUSIONS: Most outpatient UTIs in children do not require more than one healthcare visit, hospital admission, or change in empiric antibiotic therapy. This study supports the fact that pediatric UTIs can be effectively treated in the ambulatory setting.

A comparison of inpatient versus outpatient resistance patterns of pediatric urinary tract infection.

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. RESULTS: 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). CONCLUSIONS: 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.

National trends in augmentation cystoplasty in the 2000s and factors associated with patient outcomes.

PURPOSE: Augmentation cystoplasty is a major surgery performed by pediatric urologists. We evaluated national estimates of children undergoing augmentation cystoplasty in the United States for trends during the 2000s, and analyzed patient and hospital factors associated with outcomes. MATERIALS AND METHODS: Patients who underwent augmentation cystoplasty registered in the 2000 to 2009 Kids' Inpatient Database were included. Estimates of total number of augmentation cystoplasties performed and patient and hospital characteristics were evaluated for trends. Hierarchical models were created to evaluate patient and hospital factors associated with length of stay, total hospital charges and odds of having a postoperative complication. RESULTS: An estimated 792 augmentation cystoplasties were performed in 2000, which decreased to 595 in 2009 (p = 0.02). Length of stay decreased from 10.5 days in 2000 to 9.2 days in 2009 (p = 0.04). A total of 1,622 augmentation cystoplasties were included in the hierarchical models and 30% of patients had a complication identified. Patient factors associated with increased length of stay and increased odds of any complication included bladder exstrophy-epispadias complex diagnosis and older age. Pediatric hospitals had 31% greater total hospital charges (95% CI 7-55). CONCLUSIONS: The estimated number of augmentation cystoplasties performed in children in the United States decreased by 25% in the 2000s, and mean length of stay decreased by 1 day. The cause of the decrease is multifactorial but could represent changing practice patterns in the United States. Of the patients 30% had a potential complication during hospitalization after augmentation cystoplasty. Older age and bladder exstrophy-epispadias complex diagnosis were associated with greater length of stay and increased odds of having any complication.

Endoscopic subureteral injection is not less expensive than outpatient open reimplantation for unilateral vesicoureteral reflux.

PURPOSE: Extravesical ureteral reimplantation and subureteral Deflux injection are used to correct vesicoureteral reflux with success rates of 94% to 99% and up to 89%, respectively. It was reported that unilateral extravesical reimplantation may be performed safely in an outpatient setting. Given that, we analyzed total system reimbursement to compare planned outpatient unilateral extravesical reimplantation to subureteral Deflux injection in patients with unilateral vesicoureteral reflux. MATERIALS AND METHODS: Data were collected on consecutive patients undergoing outpatient procedures for unilateral vesicoureteral reflux. Assessment of total system reimbursement was made using a payer mix adjusted calculation of surgery plus anesthesia plus hospital reimbursement. This was compared per procedure and in terms of total system reimbursement for each approach to obtain a similar resolution rate. RESULTS: A total of 209 consecutive patients were identified, of whom 26 underwent subureteral Deflux injection and 183 underwent unilateral extravesical reimplantation. Mean operative time was 93 minutes for reimplantation and 45 minutes for injection. The mean volume of dextranomer-hyaluronic acid was 1.2 ml. Total initial system reimbursement per patient was $3,813 for reimplantation and $4,259 for injection. A 3% hospital admission rate for reimplantation increased the total to $3,945. Higher reimbursement for injection depended largely on the material expense for dextranomer-hyaluronic acid. CONCLUSIONS: In terms of total system reimbursement it is less expensive in our system to treat unilateral vesicoureteral reflux with unilateral extravesical reimplantation than with subureteral Deflux injection using dextranomer-hyaluronic acid. The ability to perform unilateral reimplantation as an outpatient procedure has shifted this relationship.