Journal Club

JOURNAL CLUB

COMMENTARIES BY MICHAEL J. BURKE

Persistent fever in UTIs: What does it mean?

Prolonged fever associated with urinary tract infection (UTI) is considered a clue to complications and often leads to additional diagnostic studies or prolonged hospitalizations. Now research shows that patients who have a fever for longer than 48 hours after receiving antibiotic treatment are clinically similar to those who respond to such treatment faster.

Investigators studied 288 patients with a median age of 5.6 months who had a diagnosis of pyelonephritis or UTI. At admission, all patients had a temperature of 38° centigrade or higher and a positive urine culture. By 24 hours after receiving antibiotics, 68% of patients no longer had a fever, and this figure reached 89% by 48 hours. These patients were considered "responders" Only 11% (31 patients) had fever longer than 48 hours and were considered "nonresponders." Three percent of patients were febrile beyond 72 hours.

The nonresponders did not differ in any clinical parameter—initial temperatures, white blood cell counts, band counts, presence of bacteremia, vesicoureteral reflux, hydronephrosis by renal ultrasound, and urinalyses findings—from responders except that the nonresponders were older than those whose fever resolved before 48 hours. Repeat urine cultures, performed in all the children, were sterile whatever the duration of fever. According to investigators, these findings call into question the justification for additional intervention solely because of fever that lasts for more than 48 hours, especially when antibiotic susceptibilities of the urinary pathogen, usually available by 48 to 72 hours, are known (Bachur R: Pediatrics 2000;105[5]:e59).

Commentary: Have patience with your febrile patients with UTI. This study tells us that nearly 90% of them will be afebrile in 48 hours, 97% in 72 hours.

Kawasaki disease vs. adenoviral infection

Investigators retrospectively reviewed the medical records of 36 children with Kawasaki disease (23 with classic disease and 13 with atypical presentations) and seven patients with acute adenoviral infection to determine how to differentiate between these diseases, particularly when the Kawasaki presentation is atypical. Children in the two groups did not differ significantly in age, duration of fever, number of physician visits before diagnosis, report of exposure to ill contacts, presence or absence of a rash, cervical adenopathy, or mucous membrane changes. Children with Kawasaki disease were more likely than children with adenoviral infection to have conjunctivitis, strawberry tongues, perineal peeling, and distal extremity changes. Children with acute adenoviral infection were more likely than children with Kawasaki disease to have purulent conjunctivitis and exudative pharyngitis. When children with atypical Kawasaki disease were compared with those with adenoviral infections, the differences between the groups were less striking.

Compared with those with adenovirus infection, children with Kawasaki disease had higher mean white blood cell counts, erythrocyte sedimentation rates, platelet counts, and levels of alanine aminotransferase. No child with an acute adenoviral infection had an increased transaminase level, compared with 14 of 34 children with Kawasaki disease. Of those who had a urinalysis, no child with an acute adenoviral infection (zero of six) had pyuria, compared with 13 of 27 and four of 11 children with Kawasaki disease or atypical Kawasaki disease, respectively. Mean albumin levels and hemoglobin were lower in children with Kawasaki disease than in those with adenoviral infection. Laboratory values for children with atypical Kawasaki disease differed little from the values of all children diagnosed as having Kawasaki disease.

Investigators noted that in atypical cases of Kawasaki a slitlamp examination of the eyes that shows the characteristic anterior uveitis of Kawasaki disease can make the diagnosis. Another helpful diagnostic test is a rapid direct fluorescent antigen test for adenovirus. A positive test in a child with signs and symptoms suggesting atypical Kawasaki disease may provide an alternative diagnosis and prevent administration of unnecessary immunoglobulin therapy and aspirin (Barone SR et al: Arch Pediatr Adolesc Med 2000;154:453).

Commentary: These are interesting findings, but this is a retrospective study where only 18 of 36 patients with Kawasaki disease were tested for adenovirus. Perhaps some of the untested "classic" Kawasaki was adenovirus in disguise. The take-home message is the same, however. Keep adenovirus on the differential diagnosis when considering Kawasaki disease. And if a rapid test for adenovirus is available, your threshold for using it should be low.

Urban teens speak out on pregnancy prevention

A survey of 1,000 10th and 11th graders in six Boston, MA, high schools shows that teens believe that having more information from parents, school, and health-care providers or facilities is the best way to prevent pregnancy among adolescents. Preferences for pregnancy-prevention strategies differ among teens who are abstinent or sexually active or who do or don't use contraceptives consistently, however.

The survey, which was conducted in schools whose students are at high risk for pregnancy, was evenly divided between males and females and represented diverse racial and ethnic backgrounds. It consisted of 75 multiple-choice questions and was anonymous. More than half of the students reported having had sexual intercourse (72% of males and 54% of females). The likelihood of having intercourse was highest among African-American students (77%) and lowest among Asians (7%). Of those who had sexual intercourse, only 35% used contraceptives every time, compared with 16% who used them most of the time and 49% who used them once in a while or never. Asked where they would prefer to get information on contraception, respondents were most likely to mention parents (19%), followed by community health centers, health-education classes, hospitals, and private doctors. Females were more likely than males to favor getting such information from the health-care arena; males mentioned parents and health- education classes more often than females did.

Respondents chose from a list of possible interventions what strategies they thought would prevent teen pregnancy. Overall, they were most likely to choose information about pregnancy and birth control (52%), followed by education about relationships (32.2%), communication with parents (32.5%), easy access to birth control (31%), education about the realities of parenting (30%), and a greater emphasis on delaying or abstaining from sex (26%). Abstinent teens were more likely than sexually active teens to think that more information on pregnancy and birth control would prevent pregnancy. Students who were using contraceptives consistently were more likely than inconsistent users or those who were abstinent to think that greater access to birth control methods would prevent pregnancy. Teens who used contraceptives consistently and students who were abstinent were more likely than other teens to choose a greater emphasis on abstinence and delaying sex (Hacker KA et al: J Adolesc Health 2000;26:279).

Commentary: Despite high rates of sexual activity and inconsistent use of contraceptives, very few of these teenagers wanted a baby. A surprising number did want more information about sexuality, and many of them wanted that information from their parents.

Pediatricians unaware of much physical abuse

Pediatricians often are not aware when parents of their patients are being physically abused by their spouses. In addition, a new report shows, mothers who are subject to such abuse are significantly more likely to report hitting their child hard enough to leave a mark than mothers who do not report domestic violence. Pediatricians do not identify many of these abusive parents, either.

These findings arose from interviews investigators conducted with parents of 4- to 8-year-olds and a survey of 50 pediatricians in 19 practices in a 13-town area. Clinicians provided information on each child, using a checklist of psychosocial and developmental problems. To identify domestic violence, pediatricians were asked if they had noted any spousal/partner abuse toward the mother. They also were asked whether they identified in the child physical abuse, psychological abuse, or physical neglect or had identified such problems in the past. Parents of all children who screened high risk on the Child Behavior Checklist or who the pediatrician identified with a psychosocial problem, plus a random sample of parents of children who screened negative for these problems, were invited to a 90-minute interview. To measure physical abuse, the mother was asked, "Have you ever been badly beaten or bruised by another person?" Follow-up questions identified whether the abuser was a spouse or partner. To identify harsh discipline practices, interviewers asked mothers, "Have you ever hit your children hard enough to leave a mark?"

Although 4.2% of the 939 respondents admitted to experiencing spousal or partner abuse, pediatricians identified only 0.3% of respondents as experiencing such abuse. Twenty-one percent of parents indicated that they had left a mark when they hit their children, yet pediatricians identified physical abuse in only 0.5% of patients. The study suggests that to recognize these forms of abuse pediatricians need to ask parents directly about domestic violence and harsh discipline (Kerker BD et al: Arch Pediatr Adolesc Med 2000;154:457).

Commentary: Here's another case of "don't ask, don't tell." If we don't ask about family violence, most families won't report it. If we do ask, many more will. We need to ask the questions, but we also need to be ready for the answers. Find out what resources are available in your community for adult and child victims of domestic violence.

CLINICAL TIP
For best results, don't drop the nose drops

We have noted enormous differences in individual responses when we give 1/8% Neosynephrine nose drops to infants. The key is in how the drops are administered.

We draw up the desired amount of solution into a TB syringe (minus needle) and insert the tapered end up the nose to the hub (1-cm). Then we press the plunger, quickly "injecting" the drops. The response is usually rapid—within two to five minutes—and often dramatic. We surmise that this method works so well because it bypasses much swelling and mucus and deposits the drops in a part of the nasal passages where they work best—at the so-called "nasal valve." Suctioning before giving the drops is unnecessary. We still don't know the best dose, but 0.1 mL in each of the nares in infants has worked for us.

Paul Bergeson, MD
Lindsay Campbell, MD
Phoenix, AZ

Do you have a Clinical Tip to share with colleagues? Let us know; we'll pay $50 for each item accepted for publication. Tips sent by mail should be addressed to Molly Frederick, Clinical Tips Editor, Contemporary Pediatrics, 5 Paragon Drive, Montvale, NJ 07645-1742. If you submit by e-mail (Molly.Frederick@medec.com), please include your mailing address.

 

Marian Freedman. Journal Club. Contemporary Pediatrics 2000;7:108.