抗生素英文课件精品Diagnosis and Management of VUR after first .pptVIP

Diagnosis and Management of VUR after first UTI Ron Keren, MD, MPH Division of General Pediatrics Center for Pediatric Clinical Effectiveness Children’s Hospital of Philadelphia Case 2.5 year old old white girl with 3 days of: Fever (Tmax = 40°C) Poor appetite Fussiness 2 loose stools a day Urine dip shows moderate leukocyte esterase Treatment with PO TMP/SMZ initiated Urine culture (cath specimen) grows 105 E. coli Child defervesces in 2 days and completely well in 3 days. Next steps? Screening for VUR Screening for VUR Age at First UTI Screening for VUR Management of VUR Management of VUR Current Conceptual Model What is the evidence to support current model of diagnosing and treating VUR in children after UTI? Ecological Evidence Analyses of dialysis and transplant registries Expect reduction in incidence of end stage renal disease attributable to reflux nephropathy following the diagnosis and treatment of VUR started in the 1960’s Not there Observational Studies Incidence Rates and Follow-up Incidence Rate of First UTI: 0.007/person-year Similar to previous estimates Incidence Rate of Recurrent UTI after first UTI: 0.12/person-year Significantly lower than previous estimates of 21- 48% recurrence with follow-up of 6-12 months Mean observation time was 408 days with a median of 310 days (IQR 150 – 584 days), range of 24 - 1600 days Survival Analysis Outcome is time to an event (e.g. death, recurrent infection) Observation time varies from one subject to another Different quantity Different start and stop times Censoring Types of censoring Subject does not experience event of interest Incomplete follow-up Lost to follow-up Withdraws from study Dies Hazard Ratio The hazard ratio in survival analysis is the effect of an explanatory variable on the hazard or risk of an event. Consider hazard ratio to be an estimate of relative risk Clinical Trials Systematic Review “The evidence to support the widespread use of antibiotics to prevent recurrent symptomat