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Provincialism

Organizations generally are not interested in shar-ing credit with others. For example, as a result of a $5 million legal settlement with the US Consumer Prod-uct Safety Commission, McDonald’s has been plan-ning a bicycle helmet promotion campaign. Neither McDonald’s nor the Consumer Product Safety Com-mission have shown interest in linking their effort with any others. In 1998 the Prudential Insurance Company announced a helmet promotion campaign at a well-attended press conference in the US Capitol Building. The campaign has distributed approxi-mately 15 000 helmets (R. Timms, ibid), but there has been no collaboration with other actors in the field and thus has had limited national impact.

Lack of Constituency

For action to take place, the public and policy makers must individualize an issue in human terms. In the Seattle campaign, our most persuasive moti-vational tools were media stories of brain-injured children. The media are especially attracted to the plight of prominent victims. None have stepped for-ward in the bicycle trauma realm. Victim advocacy groups have the potential power to spur action by government agencies, but have so far not done so.

In marked contrast is the vaccine constituency. Pediatricians have traditionally spent most of their “prevention energy” on immunizing American chil-dren against an ever-increasing number of infectious agents. Scorecards on percentages of “fully immu-nized” children are maintained for each state; lapses stimulate vigorous corrective action.12 _{The large}

number of physicians and other public health offi-cials interested in immunizations, along with the economic interests of the vaccine manufacturers en-sure that the issue will remain at the top of the prevention agenda.

Lack of Economic Stakes

It always helps when some deep pockets exist to fund good deeds. High stakes are present for auto manufacturers with child restraints; for pharmaceu-tical manufacturers with vaccines; and for the abate-ment industry with lead screening. In contrast the companies who produce helmets are relatively low on the capitalistic ladder. The manufacturers and mass retailers of bicycles have remained aloof from helmet promotion efforts, fearful that their popular product may be deemed “unsafe.”

CONCLUSION

There are no causes of death in children that are “worse” than others; the lives of all children are equally precious. Prevention goals should not only be set by the quantity of media attention or the strength of a constituency group. Are not the dangers to children who ride bicycles without helmets, equal or greater than the dangers to unimmunized chil-dren? We, of course, do not recommend a lessening of efforts to promote universal immunization or other effective public health measures. We do recom-mend, however, looking at all the potential agents

that can harm children; determining which are the most grievous in terms of mortality, morbidity, and disability, and for which interventions are available, and forge preventive programs accordingly. Using those criteria, prevention of bicycle-related head trauma ranks high. A coordinated national campaign to promote helmet usage is long past due.

Abraham B. Bergman, MD Frederick P. Rivara, MD, MPH Department of Pediatrics University of Washington

and the Harborview Injury Prevention and Research Center

Seattle, WA 98104

REFERENCES

1. Rogers GB. Bicycle helmet use patterns among children. Pediatrics. 1996;97:166 –173

2. Sacks JJ, Kresnow J, Houston B, Russell J. Bicycle helmet use among American children—1994.Injury Prevention.1996;2:258 –262

3. Thompson DC, Rivara FP, Thompson RS. Effectiveness of bicycle safety helmets in preventing head injuries. A case-control study.JAMA.1996; 276:1968 –1973

4. Bergman AB, Rivara FP, Richards DD, Rogers LW. The Seattle Chil-dren’s Bicycle Helmet Campaign.Am J Dis Child.1190;144:727–731 5. Rivara FP, Thompson DC, Thompson RS, et al. The Seattle Children’s

Bicycle Helmet Campaign: changes in helmet use and head injury admissions.Pediatrics.1994;93:567–569

6. Farley C, Haddad S, Brown B. The effects of a 4-year program promot-ing bicycle helmet use among children in Quebec.Am J Public Health. 1996;86:46 –51

7. Morris BA, Trimble NE. Promotion of bicycle helmet among school children: a randomized clinical trial.Can J Public Health.1991;82:92–94 8. Morris BA, Trimble NE, Fendley SJ. Increasing bicycle helmet use in a community measuring response to a wide-scale, 2-year effort.Can Fam Physician.1994;40:1126 –1131

9. Ni H, Sacks JJ, Curtis L, Cieslak PR, Hedberg K. Evaluation of a statewide bicycle helmet law via multiple measures of helmet use.Arch Pediatr Adolesc Med.1997;151:59 – 65

10. Cote TR, Sacks JJ, Lambert-Huber DA, et al. Bicycle helmet use among Maryland children: effect of legislation and education.Pediatrics.1992; 89:1216 –1220

11. Abularrage JJ, DeLuca AJ, Abularrage CJ. Effect of education and leg-islation on bicycle helmet use in a multiracial population.Arch Pediatr Adolesc Med.1997;151:41– 44

12. Centers for Disease Control and Prevention. National Immunization Survey.MMWR Morb Mortal Wkly Rep.1998;47:108 –116

Pyelonephritis at Home—Why Not?

ABBREVIATION. UTI, urinary tract infection.

I

In this issue of Pediatrics, Dr Hoberman and his colleagues have provided us with the data to justify outpatient management of the young child with suspected pyelonephritis.1 _{Children between}

the ages of 1 and 24 months who presented to emer-gency departments with fever and suspected urinary tract infection (UTI) were randomized to receive oral antibiotics at home or intravenous antibiotics in the

Received for publication Mar 22, 1999; accepted Mar 22, 1999.

Reprint requests to (M.C.F.) Section of Infectious Disease, St Christopher’s Hospital for Children, Erie Ave at Front St, Philadelphia, PA 19134-1095. PEDIATRICS (ISSN 0031 4005). Copyright © 1999 by the American Acad-emy of Pediatrics.

COMMENTARIES 109

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hospital. Three hundred six children with proven UTI were enrolled. Sterilization of urine, time for fever resolution, incidence of reinfection and inci-dence and extent of renal scarring 6 months later were not different in children treated at home with oral therapy versus those hospitalized for 3 days of parenteral therapy followed by outpatient oral anti-biotics. This is good news for children and it should be no surprise. The usual pathogen that causes UTI is

Escherichia coli; this was the causative organism in 97% of the children in this study. A variety of anti-biotics that attain high levels in urine and renal tissue have activity against this pathogen. One might ask why we ever admitted patients with pyelonephritis. Several reasons existed and continue to exist: the diagnosis is often unclear, the patients are toxic, and we fear that the infection will either damage the kidneys or spread in the child.

The diagnosis of UTI must be considered in every febrile child. Screening tests for infection should be sensitive and easy to obtain. Numerous studies have addressed the issue of screening tests, specimen col-lection and definition of UTI. The screening test used in this study was the enhanced urinalysis; this test was developed by the authors and in their hands, it is sensitive and specific for identifying patients whose urine culture will contain.50 000 colonies of a single pathogen per mL of urine.2 _{The enhanced}

urinalysis allows one to begin empiric therapy with confidence that the most likely diagnosis of the fe-brile child is infection of the urine. The enhanced urinalysis is not universally available and it is not the most cost efficient study. Dr Shaw and colleagues compared rapid tests for detecting UTI in infants and found that although the enhanced urinalysis was more sensitive than leukocyte esterase or nitrite tests, it was less specific and more costly.3_{In centers where}

the enhanced urinalysis is not available, one is left with a routine urinalysis or a dipstick of the urine. It is important to remember that pyuria occurs in a variety of disorders including viral cystitis, Ka-wasaki syndrome, and nephritis. In these illnesses, Gram stain of the urine is negative for bacteria. Un-fortunately, interpretation of the Gram stain is very labor-intensive; the accuracy of the reading depends on the skill of the microscopist. During evening and night hours, the technologist assigned to Gram stain interpretation is often the only person in the labora-tory. The time needed for careful observation and the skill needed to distinguish artifact from pathogen is often lacking. For this reason, many will rely on dipstick analysis of urine; although not as sensitive as the enhanced urinalysis, these studies will identify most infants with suspected UTI. The decision to hospitalize the child with possible UTI should be based on the degree of toxicity. It was surprising in Dr Hoberman’s study that children with bacteremia and UTI could not be distinguished from children with UTI but without bacteremia.1_Further,

bactere-mia resolved rapidly following oral or parenteral antibiotic therapy. There were no children with hy-potension in this study. All would agree that hypo-tension in a child with UTI is an indication for hos-pitalization and parenteral antibiotic therapy. The

neonate with UTI and bacteremia is at increased risk for meningitis; in my opinion, the neonate with sus-pected or proven UTI should be managed in the hospital. Finally, vomiting and degree of illness may preclude home oral antibiotic therapy. In these cases, a brief hospitalization and parenteral therapy will provide hydration, allow closer observation and en-sure antibiotic therapy is tolerated. Dr Hoberman has provided very important information regarding out-come of children who receive short courses of par-enteral antibiotics followed by oral therapy; these children did very well.

Multiple studies have revealed that over half of children with febrile UTIs have evidence of upper tract involvement.4 – 6 _{Identifying children with}

pye-lonephritis is felt to be essential so that appropriate therapy and follow-up is begun. It is notable that current recommendations for imaging and follow-up care are not based on prospective studies of out-comes in children with UTI.7_{Laboratory studies such}

as peripheral white blood cell count, sedimentation rate, and C-reactive protein are elevated in children with pyelonephritis; unfortunately, these studies are neither sensitive nor specific. The diagnosis of pye-lonephritis is based on imaging studies. The most sensitive imaging studies are nuclear scans, helical computed tomography, and nuclear magnetic reso-nance.8 _{Power Doppler is a recent addition to the}

list.9_{In the study by Hoberman et al nuclear scans}

were performed at entry and after 6 months; acute pyelonephritis was present in 61% of the children enrolled in the study.1_{Renal scarring was present at}

6 months in only 14% of the patients with pyelone-phritis. The rate of scar formation was not different in children receiving all oral therapy and those ini-tially hospitalized for three days of parenteral ther-apy. This low rate of renal scarring was attributed to surveillance for UTI in infants and prompt initiation of antibiotics.

Evaluation of the child with UTI includes imaging of the kidneys, ureters, bladder, and urethra. The timing and optimal studies remain unclear. Ultra-sound of the abdomen is easy, readily available, and involves no radiation. Ultrasound is insensitive for diagnosing pyelonephritis and vesicoureteral reflux, but is a reasonable screening study for urinary tract obstruction. It has been argued that the majority of cases of urethral values are identified on prenatal ultrasounds. Indeed, if a prenatal ultrasound has been performed, it is probably not necessary to re-peat it. In the current study, results of the ultrasound did not lead to any change in therapy and the neces-sity for the ultrasound was questioned. In previous studies where renal cortical scintigraphy has been performed, ultrasound studies have not provided additional useful information.10

Voiding cystourethrogram is obtained to identify the child with vesicoureteral reflux, bladder outlet obstruction, and bladder diverticula. The type of study and the timing of the study vary. Identification of the child with reflux is considered important; an-tibiotic prophylaxis and surgical reimplantation are used to prevent recurrent infection. There are no data to prove that either surgery or prophylaxis prevents

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renal scarring. Recently the need for obtaining a voiding cystourethrogram has been questioned.11,12

Most reflux improves or resolves over time. It re-mains unclear whether reflux of sterile urine dam-ages renal tissue. The finding of reflux in 30% to 40% of siblings of children with reflux has raised the question of whether and when siblings should be studied.13_{There are no clear answers.}

The current study did not address the follow-up of patients with pyelonephritis. Is it appropriate to look for asymptomatic bacteriuria? The authors and oth-ers have suggested that treatment of asymptomatic bacteria may be hazardous as the therapy is often followed by the occurrence of symptomatic infec-tion.6 _{If treatment is not useful, why look for the}

entity? It seems more appropriate to obtain cultures only when the child has fever or symptoms referable to the urinary tract.

This study has done us a great service by proving that most children with pyelonephritis can be man-aged as outpatients. The antibiotic used in the study was cefixime. This is reasonable for empiric therapy but is overkill for therapy of most UTIs. When anti-biotic susceptibility studies become available, it is reasonable to switch to a drug with narrow spec-trum. A side effect of broad spectrum antibiotics is alteration of bowel flora; antibiotic associated colitis or fungal overgrowth may follow. Antibiotics used for prophylaxis should be as narrow spectrum as possible; cost and side effects should also be consid-ered. Trimethoprim-sulfamethoxazole or sulfisox-azole is the usual choice for urinary tract prophy-laxis; cefixime is not an appropriate choice for prophylaxis.

Another cause of renal damage is inflammation attributable to bacteria and to the host response. As bacteria die, lipopolysaccharides are released and cytokines induced. It is not clear whether rapid kill-ing of bacteria is desirable. Perhaps, slower kill would result in less cytokine production. b-lactams are bacteriocidal and act on the cell walls; aminogly-cosides and sulfas act on protein synthesis. The ideal drug or mode of action is unknown.

Finally, a discussion of UTI is not complete with-out mention of voiding dysfunction and constipation as underlying risk factors.5_{Correction of these}

cofac-tors may be more important than antibiotic prophy-laxis or antireflux surgery.

What are the take home messages of the Hober-man study?

1. Look for UTI in febrile infants.

2. Oral antibiotics are safe and effective therapy for pyelonephritis.

3. Early therapy may prevent renal scars.

4. Many questions remain regarding follow-up, tim-ing, and type of imaging.

I look forward to future reports by the Pittsburgh group.

Margaret C. Fisher, MD Section of Infectious Disease

St Christopher’s Hospital for Children Philadelphia, PA 19134-1095

REFERENCES

1. Hoberman A, Wald ER, Hickey RW, et al. Oral versus initial intrave-nous therapy for urinary tract infections in young febrile children. Pediatrics.1999;104:79 – 86

2. Hoberman A, Wald ER, Penchansky L, Reynolds EA, Young S. En-hanced urinalysis as a screening test for urinary tract infection. Pediat-rics.1993;91:1196 –1199

3. Shaw KN, McGowan KL, Gorelick MH, Schwartz JS. Screening for urinary tract infection in infants in the emergency department: which test is best?Pediatrics.1998;101(6). URL: http://www.pediatrics.org/ cgi/content/full/101/6/e1

4. Weiss RA. Update on childhood urinary tract infections and reflux. Semin Nephrol.1998;18:264 –269

5. Rushton HG. Urinary tract infections in children epidemiology, evalu-ation, and management.Pediatr Clin North Am.1997;44:1133–1169 6. Hoberman A, Wald ER. Urinary tract infections in young febrile

chil-dren.Pediatr Infect Dis J.1997;16:11–17

7. Dick PT, Feldman W. Routine diagnostic imaging for childhood urinary tract infections: a systematic overview.J Pediatr.1996;128:15–22 8. Lavocat MP, Granjon D, Allard D, et al. Imaging of pyelonephritis.

Pediatr Radiol.1997;27:159 –165

9. Winters WD. Power Doppler sonographic evaluation of acute pyelone-phritis in children.J Ultrasound Med.1996;15:91–96

10. Sreenarasimhalah V, Alon US. Uroradiologic evaluation of children with urinary tract infection: are both ultrasonography and renal cortical scintigraphy necessary?J Pediatr.1995;127:373–377

11. Ortigas AP, Cunningham AS. Three facts to know before you order a VCUG.Comtemp Pediatr.1997;14:69:73–74

12. Friedman AL. Urinary tract infection.Curr Opin Pediatr.1998;10:197–200 13. Joseph DB. Section on Urology: report of the annual meeting, San

Francisco, California, 1995.Pediatrics.1996;99:108 –114

Community Pediatrics: Can It Be

Taught? Can It Be Practiced?

T

he report of the American Academy of

Pedi-atrics’ Committee on Community Health in the June 1999 issue ofPediatrics(pages 1304 – 1306) provides a definition of Community Pediat-rics that is much needed. Community PediatPediat-rics is more than practice in the community. Its focus is on all children, not merely those who appear in one’s practice. It also recognizes that health is the result of more than medical care and that partner-ships with public health and other professions that serve children, cultural sensitivity, and advocacy for broader services are required to achieve opti-mal health for all.

Some will argue that it is enough for a pediatri-cian to provide excellent care to those children who come to their practice, and I agree that such a goal is itself demanding. But there is a contagious aspect to many of the social and behavioral prob-lems—injuries, chemical dependency, sexual dis-eases and unplanned pregnancies, and school fail-ure—that is not dissimilar to the contagious aspect of infectious disease of a former era. They spread across communities. Why can’t departments of public health deal with these problems as they did a generation ago with contagious diseases? To

Received for publication May 3, 1999; accepted May 3, 1999.

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DOI: 10.1542/peds.104.1.109

1999;104;109

Pediatrics

Margaret C. Fisher

Why Not?

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Pyelonephritis at Home

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