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Wednesday, July 25, 2007 8:00 PM

Newscast: Lead Story - Daily Antibiotic Use to Prevent Urinary Tract Infections Can Be Harmful to Children

(opening music)

Debra: Welcome to Healthcare 411 for the week of July 25, 2007

Rand: Healthcare 411 is produced by AHRQ, the Agency for Healthcare Research and Quality, part of the U.S. Department of Health and Human Services. I’m Rand Gardner.

Debra: And I’m Debra James.

Rand: Coming up.

Debra: This week’s News and Numbers is about adverse drug events in hospitals.

Rand: A disaster planning resource helps states and local communities be aware of all health care resources that can provide assistance.

Debra: And daily antibiotics to prevent urinary tract infections may be harmful for your child. More after this.


[Begin PSA: If You’re Pregnant and You Smoke]

(baby crying)

Narrator: If you’re pregnant and you smoke, you need to know that your risk of your baby being born too small is one and a half to three and a half times greater. By quitting now, your baby has a better chance to be born at a normal weight and to have healthy lungs. But it’s also important for you to stay smoke free after your baby’s born. For free materials on quitting or to speak to a quit coach, call the National Quitline at 1-800 QUIT NOW. A message from the U.S. Public Health Service.

[End PSA]


Rand: First, the numbers.


Rand: In 2004, 1.2 million patients in hospitals experienced a problem with a medication, and 90 percent of these were due to a side effect from a medication that was given properly. Fewer than 9 percent of the adverse drug events were due to patients being given the wrong drug or the wrong dose in the hospital or because they accidentally took an overdose or the wrong drug before entering the hospital. The top three types of drugs involved in adverse drug events were corticosteroids, blood thinners, and anti-cancer drugs. Older patients an average age of 64 were more likely to suffer side effects from properly administered drugs. Patients of an average age of 47 were more likely to suffer problems after being given the wrong drug or dosage. Nearly 60 percent of all patients who experienced an adverse drug event were women. The data are from AHRQ’s Healthcare Cost and Utilization Project.

Debra: In a disaster or public health emergency, states and communities need to have a clear picture of all the health care resources that can provide assistance. AHRQ has developed a disaster planning guide called the Emergency Preparedness Atlas: U.S. Nursing Home and Hospital Facilities. It provides accurate and reliable information to help local communities identify community hospitals and nursing homes that are best prepared to provide assistance during public health emergencies. The Atlas also will help states and communities account for the elderly and people with chronic illnesses who live in nursing homes, to better protect them in an urgent situation. The Atlas includes maps for all 50 states, pinpointing the location of hospitals and nursing homes in each state. It also includes case studies from 6 states that further illustrate the locations and capacity of nursing homes and hospitals in relation to regional emergency management facilities, such as hazardous materials response, emergency management, and Red Cross chapters. A companion report to the Atlas is called Nursing Homes in Public Health Emergencies, which describes the roles that nursing homes could play in regional preparedness. For example, during a time of public emergency a nursing home could arrange with local hospitals to accept less-critically ill patients. The two reports are intended to stimulate discussions among emergency planners to help improve disaster preparation and response efforts. For more information on AHRQ-funded emergency preparedness studies, workshops, and conferences go to www.ahrq.gov/prep.


Rand: Urinary tract infections or UTIs can be a problem in children, especially for children under 6 years old. The American Academy of Pediatrics currently recommends daily antibiotics for children who have urine reflux from their bladder, but a new study found that the practice does not prevent new infections and puts children at risk for drug-resistant infections. We’re joined now by Dr. Patrick Conway, currently an assistant professor at Cincinnati Children’s Hospital. He was a Robert Wood Johnson Clinical Scholar and principal investigator for the study, which was conducted through AHRQ’s University of Pennsylvania Center for Education and Research on Therapeutics. Welcome, Dr. Conway.

Dr. Conway: Thank you for inviting me. I’m very excited to talk about this issue.

Rand: So, just how common a problem is UTIs in children?

Dr. Conway: It’s a very common problem. Three to seven percent of children have a urinary tract infection by the age of six.

Rand: Please tell us about your study.

Dr. Conway: It’s important to note that these infections are caused by bacteria, so the initial infection does need to be treated with antibiotics. So we found that daily preventive antibiotics were not effective in preventing recurrent infections, but children exposed to these antibiotics were significantly more likely to get resistant infections. When a child has a resistant infection, it means that certain antibiotics will not work to treat the infection, and therefore, there’s less options for treatment. If a child has a resistant infection, they’re more likely to need to be admitted to the hospital to receive intravenous antibiotics to treat their infection.

Rand: Are certain children are more susceptible to infections than others?

Dr. Conway: It’s one of the important aspects of the study that we wanted to investigate, so we found that children between two to six years of age had a higher risk of recurrent urinary tract infection than did children under two years of age. We found that white children were at an increased risk of getting a recurrent urinary tract infection, however, non-white children were at increased risk of getting resistant infections. The mechanism for the increased risk of resistance in non-white children is unclear and needs to be explored further.

Rand: Dr. Conway, do we know the specific cause for urinary tract infections?

Dr. Conway: The bacteria are from stool, so there’s concern that hygiene may be related with getting urinary infections. That being said, there’s probably children that also have a genetic susceptibility or an anatomic susceptibility, such as the way the urethra is positioned.

Rand: Could you please explain when preventive antibiotics are recommended?

Dr. Conway: Approximately thirty to forty percent of children with a UTI will also have a condition known as vesicoureteral reflux, which is VUR or bladder reflux. That’s a condition in which urine flows backward from the bladder towards the kidneys. We worry that this condition may predispose children to kidney damage. Currently, daily preventive antibiotics are recommended. After a first urinary tract infection, it’s recommended that we do an imaging study to see if the child has reflux from the bladder to the kidneys. This reflux is graded from one to five, with five being the worst, but most children have lower grade reflux. We found that the children with lower grade reflux had no increased risk of recurrent infections. Additionally, preventive antibiotics were not effective in preventing recurrent infections in these children.

Rand: So you don’t think these children should get daily antibiotics?

Dr. Conway: There’s a lot of people, including myself, that realize that this reflux is not the only issue. There’s kids without reflex that get mini UTIs and may benefit from antibiotics, and there’s many kids with reflux that would never get another UTI, and yet we put them on preventive antibiotics for years. It’s really the heart of the issue. I mean, unfortunately, like most things in medicine, you know, we try to make it simple, but it’s actually much more complicated, and this sort of starts to show that it’s much more complicated.

Rand: What should parents do if their child has a urinary tract infection?

Dr. Conway: In older children, UTIs are very uncomfortable and can be painful, and the child will often tell their parents that they have pain with urination or going to the bathroom. For younger children, the symptoms are harder to detect since they aren’t toilet trained and often aren’t verbal and the signs are often much more subtle, such as fever, vomiting, or general discomfort and irritability. In this case, if the parent’s worried about the child, then they should bring the child to the pediatrician so that they can make a decision on whether to test for an infection.

Rand: And if the child has a UTI then he or she should be treated with antibiotics. But after that first UTI, what should happen?

Dr. Conway: The first issue is for the clinicians to talk with the family about whether they want imaging studies performed in their child. Some of these studies involve inserting a catheter into the child and some amount of discomfort. So the first decision for the families and the clinicians is whether to pursue further imaging. The second issue to discuss with the family is whether or not to start daily preventive antibiotics in an attempt to prevent future infections. Clinicians need to talk to families about the risks and benefits so they can make a decision on whether to give the child daily preventive antibiotics or simply monitor for symptoms.

Rand: Is there anything else we can do to help inform families?

Dr. Conway: After this study I got multiple emails from families worried about their children who had had multiple recurrent urinary tract infections. I would recommend that if the child’s had multiple infections and daily preventive antibiotics are being considered, that it’s reasonable to image that child so you understand their anatomy and everything that’s going on with the child. I think there’s more research to be done on when to pursue imaging of a child with urinary tract infections, and I also think we need to pursue a clinical trial on directly comparing daily preventive antibiotics to close monitoring of the child, and we are working on both of those issues.

Rand: Dr. Conway, thank you for joining us.

Dr. Conway: My pleasure being here.

Rand: The full study is published in the July 11 issue of the "Journal of the American Medical Association."


Debra: That’s it for the week. For more information on these and other health-related stories and topics go to www.ahrq.gov. Healthcare 411 is produced by AHRQ, the Agency for Healthcare Research and Quality, part of the U.S. Department of Health and Human Services. For Rand Gardner, I’m Debra James. Please join us for the next edition of Healthcare 411.

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