Paediatrics (RCH) - Theses
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ItemUrinary tract infection in children – changing the management paradigm so more children can be treated at home( 2023-07)Urinary tract infections (UTI) are a common reason for paediatric emergency department (ED) presentations. Although most children are successfully treated with oral antibiotics, approximately one-third receive intravenous (IV) antibiotics and hospital admission. However, there is limited evidence supporting these decisions, and consequently an opportunity to approach antibiotic use differently to potentially treat more children out of hospital. Guidelines recommend most patients can be treated with oral antibiotics, but the studies used to support these guidelines excluded several cohorts. The aims of this thesis were to investigate current UTI management, particularly use of antibiotics and Hospital-in-the-Home (HITH), to define which children actually need IV antibiotics, and to explore the feasibility of using shorter IV antibiotic durations. The initial study focused on use of HITH for IV antibiotics for UTI. The study found that 90% of patients successfully completed treatment without readmission to hospital, and none became severely unwell at home. However, HITH was underused, with only 8% of patients on IV antibiotics using this model. The study supports home IV antibiotics for selected UTI management. The next study used a wider lens, examining all current UTI management in ED and found little variation in antibiotic route, choice, and duration for lower UTIs and uncomplicated upper UTIs. However, complicated upper UTIs, where there is less evidence, showed more variation. No single feature reliably predicted use of IV antibiotics, but multiple complicating factors were associated with their initiation, suggesting they represent ‘red flags’ for clinicians. In the following study, clinicians were asked why they used IV antibiotics for UTI and admitted children to hospital. Although they had defined reasons for using IV, objective clinical evidence did not always support their reasons. The study hypothesised that multiple features lead to the decision to prescribe IV antibiotics and that these features may group together. Given the finding that multiple but not always the same features led to IV antibiotic initiation, the next study aimed to develop a clinical score to determine which children need IV antibiotics. The Melbourne RUPERT score was successfully developed and tested on patients with confirmed and probable UTI. Using six clinical features, the score is straightforward, easily attainable, reproducible and aids consistent stratification of patients to determine route of initial antibiotic treatment. Finally, using outcomes and learnings from the preceding studies, a randomised control trial protocol was developed. This trial aims to investigate whether an ultra-short IV duration (1 day) is non-inferior to the standard duration for children requiring IV antibiotics. If a single daily dose of IV antibiotics followed by oral antibiotics proves sufficient, patients could be discharged home from the ED on oral antibiotics, eliminating the need for hospital admission. In questioning whether more children with UTI could be treated out of hospital, this thesis found that indeed they can, through delivering IV antibiotics at home, treating more children with oral antibiotics, and investigating an identified practice of earlier switch from IV to oral. This has the potential for major impacts on patient care and hospital sustainability.