Abstract
BackgroundThere is a lack of severity assessment tools to identify adults presenting with febrile urinary tract infection (FUTI) at risk for complicated outcome and guide admission policy. We aimed to validate the Prediction Rule for Admission policy in Complicated urinary Tract InfeCtion LEiden (PRACTICE), a modified form of the pneumonia severity index, and to subsequentially assess its use in clinical practice.MethodsA prospective observational multicenter study for model validation (2004–2009), followed by a multicenter controlled clinical trial with stepped wedge cluster-randomization for impact assessment (2010–2014), with a follow up of 3 months. Paricipants were 1157 consecutive patients with a presumptive diagnosis of acute febrile UTI (787 in validation cohort and 370 in the randomized trial), enrolled at emergency departments of 7 hospitals and 35 primary care centers in the Netherlands.The clinical prediction rule contained 12 predictors of complicated course. In the randomized trial the PRACTICE included guidance on hospitalization for high risk (>100 points) and home discharge for low risk patients (<75 points), in the control period the standard policy regarding hospital admission was applied. Main outcomes were effectiveness of the clinical prediction rule, as measured by primary hospital admission rate, and its safety, as measured by the rate of low-risk patients who needed to be hospitalized for FUTI after initial home-based treatment, and 30-day mortality.ResultsA total of 370 patients were included in the randomized trial, 237 in the control period and 133 in the intervention period. Use of PRACTICE significantly reduced the primary hospitalization rate (from 219/237, 92%, in the control group to 96/133, 72%, in the intervention group, p < 0.01). The secondary hospital admission rate after initial outpatient treatment was 6% in control patients and 27% in intervention patients (1/17 and 10/37; p < 0.001).ConclusionsAlthough the proposed PRACTICE prediction rule is associated with a lower number of hospital admissions of patients presenting to the ED with presumptive febrile urinary tract infection, futher improvement is necessary to reduce the occurrence of secondary hospital admissions.Trial registrationNTR4480 http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4480, registered retrospectively 25 mrt 2014 (during enrollment of subjects).
Highlights
There is a lack of severity assessment tools to identify adults presenting with febrile urinary tract infection (FUTI) at risk for complicated outcome and guide admission policy
The aim of the present study is to validate the PRACTICE in a new prospective cohort to guide the need for hospitalization in patients with FUTI presenting at emergency departments (ED), with the aim to reduce hospitalization rates without compromising clinical outcome
All participating centers started with a control period, in which routine clinical practice with regard to hospitalization policy was applied
Summary
There is a lack of severity assessment tools to identify adults presenting with febrile urinary tract infection (FUTI) at risk for complicated outcome and guide admission policy. We aimed to validate the Prediction Rule for Admission policy in Complicated urinary Tract InfeCtion LEiden (PRACTICE), a modified form of the pneumonia severity index, and to subsequentially assess its use in clinical practice. The majority of adults presenting to hospital with an acute febrile illness suffer from respiratory or urinary tract infections [1, 2]. For respiratory tract infection there are validated clinical rules to calculate the mortality risk, such as the Pneumonia Severity Index (PSI), which is used to provide guidance on decisions regarding treatment and hospital admission [3,4,5].
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