P2.E090: Opportunities for Antibiotic Stewardship for Pediatric Urinary Tract Infection for Outpatient Emergency Department and Urgent Care Encounters

Background: Urinary tract infections (UTI) are common causes of bacterial infections that require antibiotics. Typically, urinalysis (UA) or urine dipstick (UDip) results determine whether antibiotics are prescribed for suspected UTI. No tools were in place at our center to de-escalate or discontinue antibiotic therapy when urine culture results were negative in the emergency department (ED) or urgent care (UC). We recently instituted a dashboard to review patients with negative cultures and communicate with families to discontinue antibiotics when appropriate.

Methods: Our primary objective is to suggest opportunities for antibiotic stewardship at a large pediatric center in patients with suspected UTI that are prescribed an antibiotic but have negative urine cultures. The secondary objective is to describe prescribing patterns based on UDip or UA results, history and exam, diagnosis, antibiotic choice or duration, location of service and provider role. This retrospective chart review included patients over 60-days-old presenting to our ED or UC over a 2-year period, had a urine culture, and were prescribed antibiotics. We randomly selected a cohort of patients from this group and compared them to a group of patients with negative cultures who did not receive antibiotics to identify factors more often associated with an antibiotic prescription.

Results: Before implementing our dashboard, 26,505 urine cultures were collected in total. 88% were negative (no growth, mixed flora without a predominant organism, or < 50,000 cfu/mL of an organism). 3971 cultures (15%) were associated with an antibiotic prescription, with 2600 patients (65%) having negative cultures. Chart review of the two cohorts revealed patients discharged with antibiotics were more often prescribed Cephalexin (63.4%), compared to others, and average duration was 8.8 days (SD 1.7) with 63% of prescriptions being for a 10-day course. 51.5% patients in the antibiotic group were diagnosed with UTI, and < 3% had a cystitis or pyelonephritis diagnosis. A higher likelihood of antibiotic prescription was seen with presence of white blood cells (wbc) or bacteria on UA, urinary symptoms (dysuria or frequency), diagnoses other than UTI (otitis media or strep pharyngitis), and prescriber role (PA, NP) , with p-values < 0.05.

Conclusion: Chart review revealed many urine cultures being ordered annually, most of which result negative. Most patients prescribed antibiotics during our study period subsequently revealed negative cultures not requiring antibiotic therapy, supporting our interventions for notifying families to stop antibiotics for negative cultures. There appears to be an association between certain factors and increased likelihood of patients being discharged with antibiotics, including urinary symptoms, role of advanced practice provider (who see most of our lower acuity patients), and WBC or bacteria on UA indicating educational opportunities exist in improving diagnostic accuracy and treatment of suspected cystitis, UTI, or pyelonephritis to decrease patient exposure to unnecessary or prolonged antibiotic courses.