newsGP – New tool aims to reduce kids’ hospitalisations for UTI

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Identifying serious urinary tract infections (UTIs) in children and adolescents may now be easier with a first-of-its-kind individualised approach.

 

The new ‘RUPERT’ clinical score is designed to pick up which children have serious infections and need to be admitted to hospital, while reducing unnecessary stays for others.

 

Led by the Murdoch Children’s Research Institute (MCRI), and published in BMJ Open, the RUPERT score includes a clear list of traits that, when present at once, indicate a more serious infection – without the need for invasive or lengthy tests.

 

Infectious diseases and paediatric emergency physician, MCRI author Associate Professor Penelope Bryant, told newsGP the new tool is designed to aid decision making for appropriate treatment.

 

‘We see a lot of kids with UTI present to the emergency department (ED) … and they have a very wide range of illness from a mild infection just in the bladder, to a serious and complicated infection, including in the kidneys and sepsis,’ she said.

 

‘Those with very simple UTIs or even uncomplicated kidney infections can have oral antibiotics, but then there’s this enormous gap because over half of children who present to the ED don’t fit into those groups, and we want to address that gap in what we should do with those children.

 

‘The RUPERT score is the first of its kind anywhere and is something that’s been a difficult problem to solve.’

 

Conducted in the busy ED of Melbourne’s Royal Children’s Hospital (RCH) from May 2016 to March 2018, the researchers tested and determined a score that combines clinical features and incorporates existing evidence to assist in deciding the initial route of antibiotics in more than 1200 children with a UTI.

 

From the clinical features associated with which child needed IV antibiotics, the researchers found the fewest number of clinical features that reliably determined this was six – which defines the RUPERT score: Rigours, Urological abnormality, Pyrexia, Emesis, Recurrent UTI and Tachycardia.

 

Associate Professor Bryant said an individualised approach is key.

 

‘Previously children have been lumped together in a group of childhood UTI with a fever or with a urinary tract or abnormality, but we know the majority of these children don’t need IV antibiotics, so lumping them together doesn’t work,’ she said.

 

‘This score is trying to individualise them by taking their different clinical features and working out how many of those make the child need IV antibiotics. And that’s how we’re standardising care rather than lumping them together.’

 

Despite the RUPERT score not yet validated in general practice, Associate Professor Bryant said as ‘the same sorts of kids’ come to general practice as to EDs, the next step is to support use of the tool for GPs.

 

‘Because GPs will recognise these symptoms, whether the kid is shaking, has a fever, is vomiting,’ she said.

 

‘So, they can use the score to guide them to, “Yes, this actually supports what I was already thinking” and it gives them more confidence in making that decision, because they often don’t have all of the other tests that we have available in hospital.

 

‘GPs, like ED clinicians, are really at the frontline of making the decisions of how best to treat UTIs.’

 

While IV antibiotics are important to fast track the action such as when risk of sepsis is present, Associate Professor Bryant notes the importance of not giving IVs to children unnecessarily because of potential distress to the child and family, and admission to hospital and associated risks such as hospital-acquired infections and financial costs.

 

For all those reasons, she said ‘we really need to get it right’.

 

‘What the RUPERT score aims to help with is for the doctor with a child in front of them whom they suspect clinically of having a UTI, whether they need IV antibiotics or not,’ she said.

 

‘And they don’t need any blood tests, they don’t need even urine tests, and they certainly don’t need any imaging to be able to make a decision.’

 

Associate Professor Bryant said if a child has three or more of the six clinical features that make up the RUPERT score, they are ‘much more likely’ to need IV antibiotics. But many children may have three or less features and can ‘get away with’ oral antibiotics.

 

‘There’s no perfect way of delineating it, but there’s also been no way in the past and this is a way of guiding which children need IV antibiotics,’ she said.

 

‘Definitely if a GP thinks, “Well, they’ve only got two features, but I’m still worried about them and still going to send them to hospital,” that’s absolutely fair.

 

‘Because the same happens in the ED, but this is a way of just bolstering what the GPs’ clinical opinion is.’

UTIs are very common in children, according to Associate Professor Bryant, with around one in every 15 girls and one in every 50 boys in the general population having a UTI by the time they reach grade two.

 

For large hospitals like the Melbourne RCH, this means around 750 children a year presenting with UTI, 15 a week, or two a day.

 

And the numbers that present to general practice are likely even bigger, she said.

 

‘Because GPs see a load of kids they don’t send to the ED and parents would take their kids to the GP often before going to the ED, so the numbers are massive,’ she said.

 

‘And that’s where our interest came in – how can we solve the massive problem, rather than a problem that only affects a small number of kids?’

 

The authors conclude that with the Melbourne RUPERT score providing the first ‘standardised, easy-to-use score to aid clinicians in deciding route of antibiotics for more complicated UTI in children’, it now needs prospective validation across all healthcare settings.

 

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