antibiotic of choice for outpt pyelo management

[kat82]

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Hi everyone- just wanted to get an idea of what your antibiotic of choice was for nonpregnant outpt pyelo management. I know it largely depends on resistance patterns. We have very high cipro resistance and somewhat high bactrim resistance. I see most of these pts routinely being dc'd on a long course of either bactrim or keflex. I rarely see anyone using 3rd generation oral cephalosporins or augmentin.

I don't quite understand why keflex is routinely recommended when its a 1st generation cephalosporin, as compared to ceftriaxone, our hospitals IV/IM antibiotic of choice which is 3rd generation

What are you all prescribing out there?

Thanks!

 

[pseudoknot]

I use Keflex because it has good urinary penetration and there is very little E. coli resistance to it in my hospital.

 

[John146]

If pregnant, I give a dose of Ceftriaxone and admit. Outpatient - Cipro bid x 10-14 days

 

[TooMuchResearch]

Personally, I give a dose of Ceftriaxone and admit.

You admit everyone with pyelo? Non-pregnant, uncomplicated pyelo in an otherwise healthy patient who has access to f/u care?

 

[Rendar5]

Personally, I give a dose of Ceftriaxone and admit.

Most pyelo should be treated outpt. That said, if they have the IV, I give a dose of Ceftriaxone and d/c either on cipro or keflex. Why don't I prescribe suprax or another 3rd generation cephalosporin? Because it's not as easily afforded. Same reason I use keflex over macrobid in pregnant pts with UTI's. Same reason I only give augmentin as a second line for most illnesses (except when it is clearly first choice like bite wounds). Same reason Pen VK is first line over clinda in my mind for dental infections. Less likely to have a return visit requiring admission for lack of funds.

(oh yeah, same reason that I prescribe phenergan over zofran odt to uninsured pts and same reason I prescribed zofran 8mgODT over zofran 4mg ODT (half the cost for same number of pills), and same reason I prescribe 40/60mg pred qday over a medrol dose pack. azithro 1g over doxycycline for cervicitis, and why i specify the type of doxycycline since one is $300-400 here and the other is like $40).

 

[John146]

Sorry.. completely misread the original post. I typically use Cipro for nonpregnant outpatient treatment of pyelonephritis based on our antibiogram. If I'm admiting (intractable pain, abnormal VS, pregnant, old/comorbitities, etc), I will give a dose of Ceftriaxone and let the admitting team decide what antibiotics they want.

 

[mauricekenter]

ceftin (cefuroxime) is a 2nd generation cephalosporin and is only $11

 

[Rendar5]

ceftin (cefuroxime) is a 2nd generation cephalosporin and is only $11

Thx, might consider that one (i'm not too used to 2nd gens honestly, except for cefoxitin). Though I will say our group likes to use keflex a lot and I have yet to see someone come in with pyelo or UTI failing outpt keflex.

 

[jdh71]

Are you guys regularly making sure there are no kidney stones before sending these patients out?

 

[deleted109597]

Are you guys regularly making sure there are no kidney stones before sending these patients out?

No.

 

[Rendar5]

Only check on kidney stones if something is fishy. Such as a combo of various issues such as sick out of proportion to exam, failing output tx, a suspicious amt of RBC's, hx of infected stones. If someone is going to the ICU, I usually do check.

 

[jdh71]

Hm. I guess I didn't know you guys would send pyleo home.

It's one of these diagnoses that's always seemed like a slam dunk admit from my side of the ED.

I guess since I always going looking for a stone because they are not going to get better if an obstructing one is present and will probably crump precipitously at some point which will surprise everyone because they thought appropriate treatment was given.

What is it that makes you think in any given case that you're not just catching the patient in a snap shot window before they crump with their infected stone? I think I would check before sending anyone home.

 

[BJJVP]

Hm. I guess I didn't know you guys would send pyleo home.

It's one of these diagnoses that's always seemed like a slam dunk admit from my side of the ED.

I guess since I always going looking for a stone because they are not going to get better if an obstructing one is present and will probably crump precipitously at some point which will surprise everyone because they thought appropriate treatment was given.

What is it that makes you think in any given case that you're not just catching the patient in a snap shot window before they crump with their infected stone? I think I would check before sending anyone home.

I usually go with hx, gen appearance and sx's. If the report several days of dysuria followed by flank pain but no n/v and generally healthy, I will send home if they look good and thy are not writhing in pain. If they report sudden onset of pain, appear ill, or have othr medical problems, they ge admitted or worked up.

Its funny because an infected stone is a slam dunk for the internists but the urologists always try to send these home...at least where I work.

 

[The White Coat Investor]

Hm. I guess I didn't know you guys would send pyleo home.

It's one of these diagnoses that's always seemed like a slam dunk admit from my side of the ED.

I guess since I always going looking for a stone because they are not going to get better if an obstructing one is present and will probably crump precipitously at some point which will surprise everyone because they thought appropriate treatment was given.

What is it that makes you think in any given case that you're not just catching the patient in a snap shot window before they crump with their infected stone? I think I would check before sending anyone home.

What side of the ED are you on? I'd guess 90% of my pyelos go home, including many pregnant patients. I use a lot of keflex, and see few failures (none yet that I can think of) on keflex. Are you really suggesting we CT (or even US) all patients with pyelo? Cancer city here we come.

 

[jdh71]

I usually go with hx, gen appearance and sx's. If the report several days of dysuria followed by flank pain but no n/v and generally healthy, I will send home if they look good and thy are not writhing in pain. If they report sudden onset of pain, appear ill, or have othr medical problems, they ge admitted or worked up.

Its funny because an infected stone is a slam dunk for the internists but the urologists always try to send these home...at least where I work.

Interesting. I guess I never realized there was so much variance on this.

Urologists like to not do too much that isn't their own idea and I agree usually seems hard to get them excited about these unless you can demonstrate obstruction.

 

[jdh71]

What side of the ED are you on? I'd guess 90% of my pyelos go home, including many pregnant patients. I use a lot of keflex, and see few failures (none yet that I can think of) on keflex. Are you really suggesting we CT (or even US) all patients with pyelo? Cancer city here we come.

Well you could probably deduce what side of the ED I'm on based on the conversation.

I'm not saying anyone is "wrong" here, but rather saying I always going looking for an obstruction in any patient I've got with a pyleo because if an obstructing stone is present with pyleo that patent can crump fast. Might not make it back. That's kind of what I was thinking.

You're not going to give the patients you see with pyleo cancer by scanning them. You may have your own reason not to CT scan someone but cancer risk isn't even a viable argument. In medicine if we think the patient needs a scan, then the patient needs a scan.

 

[BJJVP]

Interesting. I guess I never realized there was so much variance on this.

Urologists like to not do too much that isn't their own idea and I agree usually seems hard to get them excited about these unless you can demonstrate obstruction.

For infected, obstructing stones, what generally happens for me is one of 2 possibilities:

1) I call hospitalist/PCP and get the pt admitted with a urology consult for the next morning.

2) If the hospitalist asks me to call urology to see if they will admit the pt, I know I will have a hard time getting a dispo because the urologist will try their hardest to send the pt home. If the pt is young, healthy, and looks good, I tend to concede and have them follow-up in the office the next morning.

If the pt is ill, older or has a lot of medical problems and needs to be admitted, I will have to call back the hospitalist and then let the urologist and hospitalist duke it out.


I have been at multiple hospitals including residency and several jobs after graduation, and while I have always been taught that an infected stone is "complicated" and therefore should be admitted, I have always received resistance from urologists regarding this point.

 

[Rendar5]

What side of the ED are you on? I'd guess 90% of my pyelos go home, including many pregnant patients. I use a lot of keflex, and see few failures (none yet that I can think of) on keflex. Are you really suggesting we CT (or even US) all patients with pyelo? Cancer city here we come.

Jdh is an intensivist I believe. All pyelo he sees is usually severe sepsis. Pyelo just happens to be a sepsis condition that can be treated outpt like it was before sirs became such a widespread criteria.

 

[southerndoc]

No.

Even pyelo with kidney stones can be sent out if they're non-toxic appearing and aren't vomiting.

 

[deleted109597]

You're not going to give the patients you see with pyleo cancer by scanning them. You may have your own reason not to CT scan someone but cancer risk isn't even a viable argument. In medicine if we think the patient needs a scan, then the patient needs a scan.

No disagreement with the second part. If they need the scan, then they absolutely need it. Unfortunately, they likely don't need more than 80% of the scans that are done. Especially the ones done for many headaches, concussions, and kidney stones.

We see a lot of pyelo that isn't "sick". Sure, they've got an infection, and maybe they meet 2 SIRS criteria. But they can go home. Flu patients can have 2 SIRS criteria.

And absolutely cancer risk is a reason not to scan. It should be a bigger reason than cost. If there is no potential benefit (ie, no change in management, etc), then the only think you have is potential harm.

 

[xaelia]

I rarely (read: never) go looking for kidney stone in an otherwise typical presentation of pyelonephritis. Usually when I'm looking for infected stone, the HPI is more consistent with ureterolithiasis than pyelonephritis, and then I'm looking for the infected, obstructing stones. Infection in the setting of stone in the otherwise healthy goes home, as well. I'd be harming way too many folks with CTs to catch the one pyelonephritis that went home and bounced back as an obstructing stone.

All our resistance patterns are relatively high here to ciprofloxacin, TMP-SMX, and cephalexin. We send a culture and then waffle back and forth between ciprofloxacin and cephalexin depending on the antibiogram of the month.

 

[Rendar5]

Dunno, I never send the pt with an infected obstructing stone home if I find the stone. Now a UTI with stone, sure because I don't know if the urinary leukocytosis is reactive or infectious, but pyelo? I've seen healthy ppl go from great to dying within 24 hours more than once from obstructive pyelo. It's essentially an abscess that needs drainage, and I"m incapable of draining it in the ED with the exception of bladder obstruction requiring a foley (only time I ever saw purulent urine outside of a urology stent placement report)

 

[jdh71]

And absolutely cancer risk is a reason not to scan. It should be a bigger reason than cost. If there is no potential benefit (ie, no change in management, etc), then the only think you have is potential harm.

There's not going to be data on this but I'd bet dollars to doughnuts the patient's "increase in cancer risk" from the isolated scan, is almost surely LESS than the risk of them dying from the possibility of whatever you are looking for in the first place. That's the thing about a scan, you don't know it's negative . . . until you do. Now, I'm not familiar with out-patient management of this phenomenon out of the ED, and I have no reason to doubt what seems to be regular management for these by you guys, but that's why I asked the question, because when these guys show up in my unit sicker than stink, if a stone hasn't been looked for, I go looking. Now, as I have already said I'm not suggesting that you all need to (I probably would, but I admittedly have a selection bias here), though all of that aside, the isolated CT scan to look for a stone, and I'll say it again: I'm not suggesting you need to do this, would be relatively negligible with regards to cancer risk. So if you're making an argument based on cancer risk for not doing it, I think that's bull****. Whatever other reasons you have, the concern about increased lifetime cancer risk by a meager 0.1% per scan when patients already have 20% chance of dying from cancer, any cancer . . . well, that seems like a pretty damn silly argument for not scanning a patient.

I find saying, "we don't scan the patient simply because we don't scan the patient," to have much more gravitas and persuasion than making any kind of argument appealing to cancer risk.

 

[deleted109597]

You rightly acknowledge your patient population having a higher incidence of badness, and again, "sick" needs the scan. I don't scan necessarily looking for the stone, but also looking for emphysematous pyelo.

That being said, if you're not scanning actively looking for something (ie, stone, or PE, or whatever), and just doing it indiscriminately, then why even have doctors? I mean, if they don't have symptoms consistent with stone, and simply have evidence of pyelo, they don't need the scan. Similarly, if they don't have symptoms consistent with PE, they don't need the scan. The gist is that not everyone with pyelo needs scanning. Of note, not everyone with a stone needs scanning either. Really, it's just the sick people. And that's all you see. It isn't all we see.

Furthermore, since the best predictor of getting an abdominal CT is prior history of an abdominal CT, yes, cancer risk is real. You may not see as many, but I see 40 year old men and women with 20+ CT scans in their short lives. None have shown anything of significance, but all they need is that first scan to destine their lives to future scans.

So yes, the people who need scans still need them, but those that don't, do not. Otherwise we wouldn't need such good clinical decision instruments as NEXUS and PECARN.

 

[jdh71]

I wasn't referring to a person who had 20 CT scans. Even then though the increrse in lifetime risk from those those 20 scans is 2% in a patient that already carries a 20% lifetime risk of any cancer.

The estimate of risk is basicslly based on extrapolated data from radiation exposure victims and its still not clear to anyone that this means its even applicable to patients in this setting. The truth is we have no REAL measure of risk from a CT scan, just the data from radiation exposure victims and an intuitive bias that zero radiation is better than a little bit of radiation but at this time its actuslly quite possible a single CT scan actually carries zero additional risk.

So my point here with regard to the scan since it was brought up, was that even if you did do them looking for stones in this population that the isolated scans would not be giving people cancer, at least not in any practical sense. And that's a stupid argument not to do one by itself. My point here regarding scans is not that you *should* scan everyone.

 

[southerndoc]

I rarely (read: never) go looking for kidney stone in an otherwise typical presentation of pyelonephritis. Usually when I'm looking for infected stone, the HPI is more consistent with ureterolithiasis than pyelonephritis

I agree. I don't scan everyone with pyelo symptoms (bilateral flank pain, dysuria, fever, etc.). If it's unilateral, then I'll scan. Even if they have a stone and UTI, if the stone isn't large (i.e., it's <5 mm), they aren't vomiting, and don't appear toxic, then they get loaded with 2 g of ceftriaxone, discuss the case with urology, and then discharge the patient with cefuroxime. Our urologists are great at following up patients quickly. (They also don't give any push back on admissions if patients need to be admitted.)

 

[deleted109597]

I wasn't referring to a person who had 20 CT scans. Even then though the increrse in lifetime risk from those those 20 scans is 2% in a patient that already carries a 20% lifetime risk of any cancer.

The estimate of risk is basicslly based on extrapolated data from radiation exposure victims and its still not clear to anyone that this means its even applicable to patients in this setting. The truth is we have no REAL measure of risk from a CT scan, just the data from radiation exposure victims and an intuitive bias that zero radiation is better than a little bit of radiation but at this time its actuslly quite possible a single CT scan actually carries zero additional risk.

So my point here with regard to the scan since it was brought up, was that even if you did do them looking for stones in this population that the isolated scans would not be giving people cancer, at least not in any practical sense. And that's a stupid argument not to do one by itself. My point here regarding scans is not that you *should* scan everyone.

You've already extended the group of people who you think need scans from those with stone symptoms to everyone with pyelo. That's a pretty big jump.
I know the data for cancer as well. And still, if you have low pretest probability, you shouldn't scan, or you are causing harm. Even if it's just a little harm.
The data for XRT forhemangiomas in Sweden is likely better than the Japan data from the bomb, and the harms of that are pretty evident.

 

[jdh71]

You've already extended the group of people who you think need scans from those with stone symptoms to everyone with pyelo. That's a pretty big jump.
I know the data for cancer as well. And still, if you have low pretest probability, you shouldn't scan, or you are causing harm. Even if it's just a little harm.
The data for XRT forhemangiomas in Sweden is likely better than the Japan data from the bomb, and the harms of that are pretty evident.

I've not extended any groups. In fact, I've went of my way to underline more than once that I'm not saying everyone needs to get scanned.

While I agree that you need to use your brain before scanning, I disagree we have any hard evidence that the isolated scan harms anyone in any real sense and I think making the claim that every scan "harms" to be pure hyperbole.

 

[deleted109597]

I've not extended any groups. In fact, I've went of my way to underline more than once that I'm not saying everyone needs to get scanned.

While I agree that you need to use your brain before scanning, I disagree we have any hard evidence that the isolated scan harms anyone in any real sense and I think making the claim that every scan "harms" to be pure hyperbole.

You disagree with the Sweden paper? It's low dose radiation, and they saw real differences in high school matriculation. Of course, it was in children.


Your first statement was to ask if we regularly rule out kidney stones before discharge, and when we said no, you said you always did. So, I would argue that you did extend it to all your patients, and your questioning makes it seem like you want us to extend it to ours as well. In fact, your wording implies that we undertest as a whole, and the reasons we use to do so are not valid.

 

[jdh71]

You disagree with the Sweden paper? It's low dose radiation, and they saw real differences in high school matriculation. Of course, it was in children.


Your first statement was to ask if we regularly rule out kidney stones before discharge, and when we said no, you said you always did. So, I would argue that you did extend it to all your patients, and your questioning makes it seem like you want us to extend it to ours as well. In fact, your wording implies that we undertest as a whole, and the reasons we use to do so are not valid.

No. That's your own garbage projected on me.

I was curious about discharging pyleo as I didn't realize it got sent out and wonder how much extra checking you did, if any prior to discharge. Thats it. Nothing implied. Anything else you read into that or implied is on you. I'm an intensivist and you know this. I do go looking for stones in all the sickies I get. Thats my context. Usually with an U/S first and if evidence of obstructive anatomy then I'll get a CT. I underlined multiple times what I was saying and what I was not and I wonder what problem you have with the written English language. When the subject of cancer and CT scans came up I simply addressed that cancer risk isn't really any issue if you are thinking or not thinking about the isolated scan. A couple of different things being discussed. I dont know what to tell you if you are unable to parse the discussion enough not to take offense.

Mostly now I'm just begining to wonder why so many emergency docs get so sensitive about things.

 

[The White Coat Investor]

Dunno, I never send the pt with an infected obstructing stone home if I find the stone. Now a UTI with stone, sure because I don't know if the urinary leukocytosis is reactive or infectious, but pyelo? I've seen healthy ppl go from great to dying within 24 hours more than once from obstructive pyelo. It's essentially an abscess that needs drainage, and I"m incapable of draining it in the ED with the exception of bladder obstruction requiring a foley (only time I ever saw purulent urine outside of a urology stent placement report)

I agree. Infected stones don't go home. In fact, most of those stones are pulled out before the sun goes down. Pus under pressure = bad

 

[The White Coat Investor]

I've not extended any groups. In fact, I've went of my way to underline more than once that I'm not saying everyone needs to get scanned.

While I agree that you need to use your brain before scanning, I disagree we have any hard evidence that the isolated scan harms anyone in any real sense and I think making the claim that every scan "harms" to be pure hyperbole.

Every scan doesn't harm, but the best data I've seen suggests that a single CT scan in a young person (say, under 25) will eventually cause a fatal cancer in something between 2000 and 5000. Now, you only order CTs in people that are pretty high risk of dying of something else, and who tend to be old and sick. I, however, probably order a CT in something like 25-33% of my patients for one indication or another, many of whom are young. A typical trauma center trauma patient is likely to get 4 (head, C-spine, chest, abd/pelvis), twice that many if admitted.

So if I'm ordering 4-8 CTs per shift, and working 15 shifts per month, that means I'm killing someone every 2-3 years from radiation. A bigger problem is the frequent flier ED patient, who for whatever reason (poorly treated anxiety, drug-seeking behavior, chronic/recurring illness) gets lots of CT scans. If 1 in 2000 scans in a 20 year old will kill someone, how about the patient who has had 15 CT scans in the last year who I scan again? I don't even want to know the numbers. I'll bend over backwards to avoid scanning this patient again (bring him back in 12 hours, use an US, suggest an ex-lap instead etc.)

This is a huge issue in EM right now. There are many things pushing an EP to get more scans:

Less liability
Less likely to miss a serious diagnosis
You can bill more due to a higher level of care
The hospital and radiologist make more (and your contract gets more secure)
The patients want it
Therapeutic radiation (poorly understood phenomenon where taking a picture of something makes the patient feel better)

but the reasons NOT to get a CT scan don't hurt the physician or the hospital, but can be very harmful to the patient.

The patient saves money
The insurance company (and "the system") saves money
The patient might get cancer
The patient might have an allergic reaction to contrast
The patient might have contrast related kidney injury.

So we've got our pocketbook vs our Hippocratic oath here, and I'm sad to say that the pocketbook wins this battle a little too often.

 

[ORL10]

I am surprised you are sending home infected stones. If there is any hydro at all, there is a physiologic obstruction to the flow of urine increasing the likelihood of outpatient failure.

If the patient looks well, is not vomitting, has no CVA tenderness and no fever how did you come to the conclusion they had pyelo?

Lastly, for all the admissions of low risk chest pain, syncope, chronic back pain in which the utiltiy of a tele admission or floor admission in general is 0, I'm surprised on the resistance to admit a patient with real pathology and a chance of turning south, quickly.

 

[deleted109597]

No. That's your own garbage projected on me.

Guess I just misunderstood these lines.

Are you guys regularly making sure there are no kidney stones before sending these patients out?

Hm. I guess I didn't know you guys would send pyleo home.

As far as this,

When the subject of cancer and CT scans came up I simply addressed that cancer risk isn't really any issue if you are thinking or not thinking about the isolated scan. A couple of different things being discussed. I dont know what to tell you if you are unable to parse the discussion enough not to take offense.

No. Cancer risk is an issue for us. It isn't for you. Perhaps you can get that through your head eventually.

Mostly now I'm just begining to wonder why so many emergency docs get so sensitive about things.

You're the one who keeps saying things like garbage and bull****. I'm not sensitive. I'm trying to teach.

 

[jdh71]

Guess I just misunderstood these lines.

Clearly 🙂

No. Cancer risk is an issue for us. It isn't for you. Perhaps you can get that through your head eventually.

You're the one who keeps saying things like garbage and bull****. I'm not sensitive. I'm trying to teach.

And what I'm trying to teach you is that cancer "risk" which may not even exist for the isolated scan, if it does exist is really negligible in the context everything else.

You are free to be afraid of ghosts if you want.

 

[Rendar5]

He did provide you with a paper that does show risk of scans to be fair. Our population is different than yours in that there are plenty of extremely healthy people with very little wrong with them most of the time. In an ICU pt, scan away. I've never seen a PICU attending shy away from a CT before, and the peds crowd is one that we get to be especially conscious of. But in a non-ICU pt, radiation risk becomes something to consider, especially in the under 25 crowd and the pregnant crowd. but I doubt you'll see an ED doc concerned about cancer risk when dealing with a late middle-aged to elderly pt. It's all about population selection/risk stratification. same thing we get to deal with when getting undifferentiated chest pain coming in.

 

[deleted109597]

Clearly we are never going to agree on this.
http://drjengunter.wordpress.com/2013/09/22/why-the-radiation-of-a-chest-or-dental-x-ray-isnt-the-same-as-2-days-in-denver/

Again I state that if there is no potential benefit, then all that is left is potential harm (stolen from xaelia). Even benign interventions are harmful. We had 2 people in Texas die recently after getting calcium gluconate that was contaminated.

 

[jdh71]

He did provide you with a paper that does show risk of scans to be fair. Our population is different than yours in that there are plenty of extremely healthy people with very little wrong with them most of the time. In an ICU pt, scan away. I've never seen a PICU attending shy away from a CT before, and the peds crowd is one that we get to be especially conscious of. But in a non-ICU pt, radiation risk becomes something to consider, especially in the under 25 crowd and the pregnant crowd. but I doubt you'll see an ED doc concerned about cancer risk when dealing with a late middle-aged to elderly pt. It's all about population selection/risk stratification. same thing we get to deal with when getting undifferentiated chest pain coming in.

The paper he brought up didn't even mention cancer which was the topic was it not? So now its not cancer now but it's risk to IQ as extrapolated by exposure to radiation in utereo. Unless we are talking about two difference Swedish papers. I stil fail to see how it's germane to the discussion I'm having about adult patients.

 

[jdh71]

Clearly we are never going to agree on this.
http://drjengunter.wordpress.com/2013/09/22/why-the-radiation-of-a-chest-or-dental-x-ray-isnt-the-same-as-2-days-in-denver/

Again I state that if there is no potential benefit, then all that is left is potential harm (stolen from xaelia). Even benign interventions are harmful. We had 2 people in Texas die recently after getting calcium gluconate that was contaminated.

The always the potential for *something*. There's also potential of any action being neutral. Saying things are only possibly good or bad is a false dichotomy. And appealing to rather vague and unproven "potentials" doesn't seem like a very intellectually honest way to work through the issue.

Though you seem to think I've been advocating for scans without a reason. I've told you more than once that I am not. I don't understand you disconnect and inability to understand what is being said and what is not. Try and keep the discussion to the discussion if you can.

 

[Arcan57]

jdh71,
Scanning for stones is a question of risk. While it wouldn't even be ethical to do the study, the yield of CTs in our patient population for patients we aren't suspecting stones in would be extremely low. While I agree that the studies underpinning the cancer risk argument aren't as rigorous as one would like, the triple end-point of cancer, therapeutic misadventure occasioned by benign incidentalomas, and financial cost to the patient make a compelling reason in the low to very low risk patient to avoid CT scanning. I'll buy that patients sick enough to land in the ICU from pyelo need a scan, but I'm usually the one ordering it because I'm hunting for something besides the UTI as cause of severe sepsis/septic shock. The disease you see in the ICU is all sorts of badness, but your population represents maybe 1:100 of patients with UTI that meets SIRS criteria.

 

[The White Coat Investor]

Lastly, for all the admissions of low risk chest pain, syncope, chronic back pain in which the utiltiy of a tele admission or floor admission in general is 0, I'm surprised on the resistance to admit a patient with real pathology and a chance of turning south, quickly.

First, not every ED admits a lot of low risk chest pain. The vast majority of my chest pain patients go home. I get stress tests within 1-2 days routinely as outpatients and have a fairly low risk population.

Second, low risk syncope goes home too. I don't consider a 70 year old who passed out low risk, however, unless they've got an ICD I can interrogate to rule out arrythmia. But I still get a lot of pushback when I admit those.

Third, chronic back pain? Who admits that? That doesn't even get IV narcs in my ED. That gets a medical screen out.

There is a lot of grey between cystitis and pyelonephritis. WBC 13 and dirty urine. Left flank tenderness and dirty urine. 15 WBCs in the urine and one episode of vomiting. Temp 101 and 10 WBCs in the urine. It's not nearly as clearcut as a lot of people seem to think, which isn't surprising given the pathophysiology. Plus, lots of them don't want to be admitted and would like to try outpatient treatment first.

 

[kat82]

fascinating discussion here, thank you all for your replies. I agree that not every pyelo pt needs a CT scan for reasons listed above. In fact the few times I've found pyelo with obstructive stones, those pts are super sick. So any ill appearing pyelo gets imaging to rule out stone AND renal abscess.

Has anyone given thought to renal ultrasound in patients who you think *may* have a stone but your suspicion is fairly low? I often do this- if there's no hydro on ultrasound, theres no clinically significant stone where my management would be changed (outpt antibiotics and close follow up). I do renal ultrasound on my pts with recurrent kidney stones to confirm the diagnosis as well. If there is no hydro, I'll think long and hard about possibly missing an alternate dx

 

[Arcan57]

fascinating discussion here, thank you all for your replies. I agree that not every pyelo pt needs a CT scan for reasons listed above. In fact the few times I've found pyelo with obstructive stones, those pts are super sick. So any ill appearing pyelo gets imaging to rule out stone AND renal abscess.

Has anyone given thought to renal ultrasound in patients who you think *may* have a stone but your suspicion is fairly low? I often do this- if there's no hydro on ultrasound, theres no clinically significant stone where my management would be changed (outpt antibiotics and close follow up). I do renal ultrasound on my pts with recurrent kidney stones to confirm the diagnosis as well. If there is no hydro, I'll think long and hard about possibly missing an alternate dx

Who's providing the close outpatient f/u in patients with UTIs? Uro isn't going to touch them and in many cases if they had access to primary care they wouldn't have ended up in the ED. U/S is a useful adjunct in the patient that already has a urologist to prove that they're fine to wait for f/u, but if they're not already hooked up then you're rolling the dice.

 

[ORL10]

First, not every ED admits a lot of low risk chest pain. The vast majority of my chest pain patients go home. I get stress tests within 1-2 days routinely as outpatients and have a fairly low risk population.

Second, low risk syncope goes home too. I don't consider a 70 year old who passed out low risk, however, unless they've got an ICD I can interrogate to rule out arrythmia. But I still get a lot of pushback when I admit those.

Third, chronic back pain? Who admits that? That doesn't even get IV narcs in my ED. That gets a medical screen out.

There is a lot of grey between cystitis and pyelonephritis. WBC 13 and dirty urine. Left flank tenderness and dirty urine. 15 WBCs in the urine and one episode of vomiting. Temp 101 and 10 WBCs in the urine. It's not nearly as clearcut as a lot of people seem to think, which isn't surprising given the pathophysiology. Plus, lots of them don't want to be admitted and would like to try outpatient treatment first.

Your practice may represent a small minority of the general ED's. Lots of people admit chest pain, or they admit to obs for stress testing which is the same as admitting (despite the futility of stress testing being demonstrated over and over again).

When you say low risk syncope I think of an ed doc sending home a 25 y/o who passed out in church. In reality syncope results in >50% admission rate, and a serious adverse event rate typically between 5-15% depending. Most of these people are slam dunk admission (hypoxia, hypotension, anemia, CHF etc..) Yet still many other patients are admitted, with minimal benefit.

I'm just saying that pyelo with a stone is as deserving as an admission as syncope

As for US i think it can be helpful in predicting patients likely to develop complications (hydro, abscess, masses etc.) In older patients with more comorbidities CT can be useful to exclude other processes that are frequently missed by ED's initially by being called pyelo or nephrolithiasis because of there similar presentation (i.e; renal infarct.)

 

[deleted109597]

Your practice may represent a small minority of the general ED's. Lots of people admit chest pain, or they admit to obs for stress testing which is the same as admitting (despite the futility of stress testing being demonstrated over and over again).

Nah, lots of residency programs admit a lot of chest pain. Lots of community places cannot admit 60% of the patients that walk in the door, and thus are sent out. I would argue his practice represents the majority.

When you say low risk syncope I think of an ed doc sending home a 25 y/o who passed out in church. In reality syncope results in >50% admission rate, and a serious adverse event rate typically between 5-15% depending. Most of these people are slam dunk admission (hypoxia, hypotension, anemia, CHF etc..) Yet still many other patients are admitted, with minimal benefit.

Then stop doing it. Standard of care is what doctors in your location do. Change it.

I'm just saying that pyelo with a stone is as deserving as an admission as syncope

As for US i think it can be helpful in predicting patients likely to develop complications (hydro, abscess, masses etc.) In older patients with more comorbidities CT can be useful to exclude other processes that are frequently missed by ED's initially by being called pyelo or nephrolithiasis because of there similar presentation (i.e; renal infarct.)

Older people are the ones we generally don't care about the radiation on. We're talking about young people generally.
And we still don't go looking for stones on every pyelo patient.

 

[deleted109597]

The paper he brought up didn't even mention cancer which was the topic was it not? So now its not cancer now but it's risk to IQ as extrapolated by exposure to radiation in utereo. Unless we are talking about two difference Swedish papers. I stil fail to see how it's germane to the discussion I'm having about adult patients.

It's still a potential harm. I didn't say cancer was the only risk, just one of them.

The always the potential for *something*. There's also potential of any action being neutral. Saying things are only possibly good or bad is a false dichotomy. And appealing to rather vague and unproven "potentials" doesn't seem like a very intellectually honest way to work through the issue. .

You're dealing with the same vaguarities just in a different direction. You just don't want to consider the harm, and again, in your patient population, that's valid.
I'd like to see the paper that proves CTs have no harm, because I guarantee you don't have a reference for that. But for some reason your unproven stance feels "right" because the potential harm is pushed way down the road, and you're not ordering double digit CTs per day like some busy EPs. It absolutely is intellectually honest to consider the best evidence, which is that ionizing radiation causes harm. Just because we don't have RCTs for CT scans doesn't mean it isn't true. And yes, there are neutral things, but even neutral things cause harm.
So again I ask because you keep skirting around it. If CTs are so benign, why are there numerous papers out there for reducing their use? New Orleans, Ottawa, NEXUS, PECARN, etc? Are they just idiots increasing their risk of missing stuff? Or people with rational concerns?

 

[jdh71]

jdh71,
Scanning for stones is a question of risk. While it wouldn't even be ethical to do the study, the yield of CTs in our patient population for patients we aren't suspecting stones in would be extremely low. While I agree that the studies underpinning the cancer risk argument aren't as rigorous as one would like, the triple end-point of cancer, therapeutic misadventure occasioned by benign incidentalomas, and financial cost to the patient make a compelling reason in the low to very low risk patient to avoid CT scanning. I'll buy that patients sick enough to land in the ICU from pyelo need a scan, but I'm usually the one ordering it because I'm hunting for something besides the UTI as cause of severe sepsis/septic shock. The disease you see in the ICU is all sorts of badness, but your population represents maybe 1:100 of patients with UTI that meets SIRS criteria.

I get it. I didn't say you guys need to or should CT scan all these patients. I said I look, which was why I asked the original question. I'm not sure how often to repeat that before I'm not longer misunderstood.

Curiosity may not kill the car but it apparently gets more than a few offended responses in the EM forum. 😉 😎

 

[jdh71]

You're dealing with the same vaguarities just in a different direction. You just don't want to consider the harm, and again, in your patient population, that's valid.
I'd like to see the paper that proves CTs have no harm, because I guarantee you don't have a reference for that. But for some reason your unproven stance feels "right" because the potential harm is pushed way down the road, and you're not ordering double digit CTs per day like some busy EPs. It absolutely is intellectually honest to consider the best evidence, which is that ionizing radiation causes harm. Just because we don't have RCTs for CT scans doesn't mean it isn't true. And yes, there are neutral things, but even neutral things cause harm.
So again I ask because you keep skirting around it. If CTs are so benign, why are there numerous papers out there for reducing their use? New Orleans, Ottawa, NEXUS, PECARN, etc? Are they just idiots increasing their risk of missing stuff? Or people with rational concerns?

It would be the same study that would prove harm or not harm so the reason you don't have the study is the same reason I don't.

I honestly don't think I've been this misunderstood in a discussion in a long time.

I never said that there was not any "potential harm". My point was the regarding the isolated CT and *if* estimates of the life time cancer risks increase are correct, and it's not for sure that they are, then that increase is really negligible within the context of total lifetime risk for ANY cancer.

And folks are interested in reducing scan for any number of reasons none of which are germane or important to the point I am making because I'm not endorsing a bunch of CT scan. I already do plenty following pulmonary nodules. I'm not interested in more.

 

[KnuxNole]

First, not every ED admits a lot of low risk chest pain. The vast majority of my chest pain patients go home. I get stress tests within 1-2 days routinely as outpatients and have a fairly low risk population.

Second, low risk syncope goes home too. I don't consider a 70 year old who passed out low risk, however, unless they've got an ICD I can interrogate to rule out arrythmia. But I still get a lot of pushback when I admit those.

Third, chronic back pain? Who admits that? That doesn't even get IV narcs in my ED. That gets a medical screen out.

There is a lot of grey between cystitis and pyelonephritis. WBC 13 and dirty urine. Left flank tenderness and dirty urine. 15 WBCs in the urine and one episode of vomiting. Temp 101 and 10 WBCs in the urine. It's not nearly as clearcut as a lot of people seem to think, which isn't surprising given the pathophysiology. Plus, lots of them don't want to be admitted and would like to try outpatient treatment first.

I got an admission or two for chronic back pain.


Actually the stuff you said you would send home are all stuff I admitted in the past 3 months >_> Honestly, I didn't know that people sent chest pain home that often. It seems anyone with chest pain and/or syncope gets an auto admit here

 

[Apollyon]

I honestly don't think I've been this misunderstood in a discussion in a long time.

With respect, just a note: if you think everyone else has the problem, you have the problem.

If you are being misunderstood so frequently and so strongly, I would think that the onus is on you to clear things up; I would not conclude that EM docs are just thin-skinned.

With respect.