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Key Feature 1: Take an appropriate history and do the required testing to exclude serious complications of urinary tract infection (UTI) (ex: sepsis, pyelonephritis, impacted infected stones).
Skill: Clinical Reasoning Phase: Hypothesis generation, Investigation Key Feature 2: Appropriately investigate all boys with urinary tract infections, and young girls with recurrences (ex: ultrasound). Skill: Clinical Reasoning Phase: Investigation Key Feature 3: In diagnosing urinary tract infections, search for and/or recognize high-risk factors on history (ex: pregnancy, immune compromise, neonate, a young male, or an elderly male with prostatic hypertrophy). Skill: Clinical Reasoning Phase: Hypothesis generation, History Urinary tract infections are extremely common, and most of the time they aren't complicated. When someone presents to my clinic with symptoms in keeping with a UTI (dysuria, urinary frequency and urgency +/- hematuria +/- suprapubic pain), it's my job to ensure that they don't have symptoms and signs suggesting a more complicated picture. The following features on clinical assessment take a UTI from simple to complicated:
All patients with features suggesting a complicated UTI warrant referral to the nearest ED for further workup. Beyond routine and microscopic urinalysis as well as urine culture and sensitivity, blood cultures are warranted if you are thinking about possible sepsis. In terms of imaging, if you are thinking about pyelonephritis, obtain a CT abdo/pelvis with contrast, and if you are thinking about infected kidney stones, obtain a non-contrast CT abdo/pelvis. If you wish to avoid contrast and have the option, consider starting with a renal ultrasound instead. Speaking of renal ultrasound, besides its utility in looking for pyelonephritis or nephrolithiasis, it is also useful to look for urinary tract malformations in pediatric patients when indicated. As in the adult population, UTIs are much more common in females as their urethral tract is much shorter and they are therefore at greater risk of bacteria finding their way up and into the bladder. However, recurrent UTIs in prepubertal females are not common, and any UTIs in prepubertal males are unusual. UpToDate recommends obtaining renal and bladder ultrasonography if the following indications are met:
Children should also be sent for a voiding cystourethrogram to look for vesicoureteral reflux if the following indications are met:
So now I've singled out two groups to be weary of with suspected UTI: those who have features suggestive of a complicated UTI and children with suspected UTI. Other groups that require special considerations, and the considerations they warrant, are as follows. Note that any patients with a suspected complicated UTI, recurrent UTI, or any features below warrant at the very least a urinalysis and urine culture & sensitivity.
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Antibiotics
Key Feature 1: In patients requiring antibiotic therapy, make rational choices (i.e., first-line therapies, knowledge of local resistance patterns, patient’s medical and drug history, patient’s context). Skill: Clinical Reasoning, Selectivity Phase: Treatment Key Feature 4: Use a selective approach in ordering cultures before initiating antibiotic therapy (usually not in uncomplicated cellulitis, pneumonia, urinary tract infections, and abscesses; usually for assessing community resistance patterns, in patients with systemic symptoms, and in immunocompromised patients). Skill: Selectivity Phase: Investigation Fever Key Feature 3: In a febrile patient requiring antibiotic therapy, prescribe the appropriate antibiotic(s) according to likely causative organism(s) and local resistance patterns. Skill: Clinical Reasoning Phase: Treatment Infections Key Feature 1a: In patients with a suspected infection: Determine the correct tools (ex: swabs, culture/transport medium), techniques, and protocols for cultures. Skill: Clinical Reasoning Phase: Investigation Key Feature 1b: In patients with a suspected infection: Culture when appropriate (ex: throat swabs/sore throat guidelines). Skill: Clinical Reasoning, Selectivity Phase: Investigation Key Feature 2a: When considering treatment of an infection with an antibiotic, do so: Judiciously (ex: delayed treatment in otitis media with comorbid illness in acute bronchitis). Skill: Clinical Reasoning, Selectivity Phase: Treatment Key Feature 2b: When considering treatment of an infection with an antibiotic, do so: Rationally (ex: cost, guidelines, comorbidity, local resistance patterns). Skill: Clinical Reasoning, Selectivity Phase: Treatment Key Feature 5: When a patient returns after an original diagnosis of a simple infection and is deteriorating or not responding to treatment, think about and look for more complex infection. (i.e., When a patient returns complaining they are not getting better, don’t assume the infection is just slow to resolve). Skill: Clinical Reasoning Phase: Hypothesis generation Pneumonia Key Feature 5: Identify patients, through history-taking, physical examination, and testing, who are at high risk for a complicated course of pneumonia and would benefit from hospitalization, even though clinically they may appear stable. Skill: Selectivity Phase: Diagnosis Key Feature 7: For a patient with a confirmed diagnosis of pneumonia, make rational antibiotic choices (ex: outpatient + healthy = first-line antibiotics; avoid the routine use of “big guns”). Skill: Clinical Reasoning, Professionalism Phase: Treatment Key Feature 8a: In a patient who is receiving treatment for pneumonia and is not responding: Revise the diagnosis (ex: identify other or contributing causes, such as cancer, chronic obstructive pulmonary disease, or bronchospasm), consider atypical pathogens (ex: Pneumocystis carinii, TB), and diagnose complications (ex: empyema, pneumothorax). Skill: Clinical Reasoning Phase: Hypothesis generation, Diagnosis Key Feature 8b: In a patient who is receiving treatment for pneumonia and is not responding: Modify the therapy appropriately (ex: change antibiotics). Skill: Clinical Reasoning Phase: Treatment, Diagnosis Key Feature 10: In patients with a diagnosis of pneumonia, ensure appropriate follow-up care (ex: patient education, repeat chest X-ray examination, instructions to return if the condition worsens). Skill: Clinical Reasoning Phase: Follow-up Key Feature 11: In patients with a confirmed diagnosis of pneumonia, arrange contact tracing when appropriate (ex: in those with TB, nursing home residents, those with legionnaires’ disease). Skill: Clinical Reasoning Phase: Follow-up, Referral Urinary Tract Infection Key Feature 4: In a patient with a diagnosed urinary tract infection, modify the choice and duration of treatment according to risk factors (ex: pregnancy, immunocompromise, male extremes of age); and treat before confirmation of culture results in some cases (ex: pregnancy, sepsis, pyelonephritis). Skill: Selectivity Phase: Treatment When I think a patient is likely to have a bacterial infection, I turn to Bugs & Drugs, the app on my phone that guides me to select appropriate investigations and empiric antibiotics as I await the results. This resources takes into account local resistance patterns and has a whole many other features including how to tailor antibiotics for specific bugs and gold nuggets of clinical information that are concise and ever-so-helpful regarding patient management. It gives you options for first-line choices and second-line choices in case a patient is allergic to the preferred option, or depending how unwell they are or are at risk for becoming. It even has risk calculator scores such as the CURB-65 to help determine patient disposition for those diagnosed pneumonia (Calculate by QxMD is another medical app filled with useful risk score calculators to support clinical decision making). Bugs & Drugs was originally developed to assist physicians in Alberta make appropriate antibiotic selection, but being only one province over, generally the microorganism resistance patterns are similar and so the recommendations also typically apply in the province of BC. There is another app I use called Spectrum that is far less glorious but that has even more targeted antimicrobial suggestions for patients in Vancouver specifically. I use this app to cross-reference Bugs & Drugs if it has information for the same infection. (If there is discrepancy, I make a judgment call all facts considered, but typically I default to Spectrum if I have to make a difficult choice, because it is designed to be more attune to the local microorganism resistance exactly where I am.) Bugs & Drugs unfortunately is not free from the app store, but I GUARANTEE that if you're a physician in Western Canada and you haven't tried it, it'll be some of the best less-than-$20 you'll ever spend on your CME. Got a question on a bug or a drug? Chances are it will solve your woes. Get at it. Does one need to obtain microbial studies prior to starting empiric antibiotics? It is often ideal to know what you're treating to be able to select appropriate antibiotics; empiric antibiotics are designed as a best guess option considering the bugs that are typically responsible for the given infection. However, with some run-of-the-mill infections, the bugs are so notoriously common for the infection that empiric treatment can be started without the need for definitive results from a microbial culture. This would apply to uncomplicated cellulitis, pneumonia, urinary tract infection, and abscesses. Treating empirically is standard of care for these infections. However, a patient should be advised to follow-up if they continue to worsen or simply aren't responding to antibiotic treatment as expected, as there could be more going on than was apparent clinically (ex: microorganisms with antibiotic resistance, atypical pathogens, complication or comorbid disease process, wrong diagnosis, etc.) and they may need further investigations and/or a change in their treatment regimen. If atypical organisms are responsible for the infection then public health authorities may need to be notified in the interest of contact tracing and prevention of outbreaks of infectious disease. Some types of infection may not need treatment at all in an otherwise healthy person with a good immune system, or at least can be postponed with clinical observation as their resolution with and without antibiotics is just not significantly different, or worth the side effects of the medicine. If, on the other hand, the patient appears unwell or would be at risk of decompensation, obtaining microbial cultures and providing empiric treatment is warranted even for infections that usually have the typical and well-characterized bacterial causes, because the stakes are just higher. Another time to consider getting microbial cultures would be if there is an active public health strategy to characterize regional infection rates, with corresponding microbial sensitivities to assess local microorganism resistance patterns. By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Fever Key Feature 1a: In febrile infants 0-3 months old: Recognize the risk of occult bacteremia. Skill: Clinical Reasoning Phase: Hypothesis generation, Diagnosis Key Feature 1a: In febrile infants 0-3 months old: Investigate thoroughly (ex: blood cultures, urine, lumbar puncture +/- chest X-ray). Skill: Clinical Reasoning Phase: Investigation Key Feature 8: In an elderly patient, be aware that no good correlation exists between the presence or absence of fever and the presence or absence of serious pathology. Skill: Clinical Reasoning Phase: Hypothesis generation Newborn Key Feature 2a: In a newborn, where a concern has been raised by a caregiver (parent, nurse): Think about sepsis. Skill: Clinical Reasoning Phase: Hypothesis generation Key Feature 2b: In a newborn, where a concern has been raised by a caregiver (parent, nurse): Look for signs of sepsis, as the presentation can be subtle (i.e., not the same as in adults, non-specific, feeding difficulties, respiratory changes). Skill: Clinical Reasoning, Selectivity Phase: Physical, History Key Feature 2c: In a newborn, where a concern has been raised by a caregiver (parent, nurse): Make a provisional diagnosis of sepsis. Skill: Clinical Reasoning Phase: Diagnosis Urinary Tract Infection Key Feature 5: Given a non-specific history (ex: abdominal pain, fever, delirium) in elderly or very young patients, suspect the diagnosis and do an appropriate work-up. Skill: Clinical Reasoning Phase: Hypothesis generation, Investigation When I was in my third year of medical school I encountered a febrile infant in clinic who was just over a month old. My attending family physician recommended the parents bring their infant immediately to the Emergency Department, and because I was on a rural rotation, I had the privilege of heading over to the Emergency Department myself to follow the workup through. My preceptor urgently referred this infant to the Emergency Department because of the heightened risk of occult bacteremia in febrile infants under 3 months of age. According to the UpToDate article, Febrile infant (younger than 90 days of age): Definition of fever (2018), "Neonates and young infants may manifest fever as the only sign of significant underlying infection. The incidence of serious bacterial infection such as urinary tract infection, bacteremia, meningitis, and pneumonia is higher in infants younger than three months of age, particularly those under 28 days, than at any other time in childhood. In addition, these young patients can experience significant morbidity from some viral infections." A fever in a child less than 3 months old warrants an urgent workup in an Emergency Department as this can be the first sign of a potentially life-threatening infection/sepsis. The Emergency Department is the place in our healthcare system where this workup can be completed the most urgently and with the resources to do so as extensively as indicated. So what exactly does the workup of a febrile infant less than 3 months of age entail? Per the UpToDate article, Approach to the ill-appearing infant (younger than 90 days of age) (2018), and the BC Children's Hospital Febrile Infant Guideline, the investigations that are indicated in this situation include:
I also just want to make a little pitch here about fever in the other extreme of age. Like infants, elderly patients may be impaired in their ability to mount a significant immune response to an invasive infection, and may not even develop a temperature high enough to be considered febrile (typically around 38 degrees Celsius). It is important - when encountering a newborn or elderly patient who is unwell - to have a high index of suspicion for a source of infection, even if they aren't presenting with a fever. While the infant I encountered on this occasion had mounted a fever, other signs of sepsis to watch out for are included in the below table from UpToDate:  Furthermore, per UpToDate, "A clinical diagnosis of severe sepsis or septic shock is made in children who have signs of inadequate tissue perfusion, two or more criteria for the systemic inflammatory response syndrome (SIRS), and suspected or proven infection." See below for a table provided by UpToDate of the pediatric SIRS criteria:  |
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