P2.Q331: Reducing Unnecessary UTI Screening and Antibiotic Treatment in Pediatric Urgent Care, a Quality Improvement Initiative

Purpose/Objectives: Urinary tract infection (UTI) stands among the most prevalent bacterial infections in children, often considered in cases of fever, abdominal pain, and/or vomiting in Urgent Care (UC). Urine culture (UCx) serves as the gold standard for diagnosis; yet delayed results (2-3 days), leads to starting empiric antibiotics (Abx) in suspected UTI cases. This practice can result in unnecessary Abx exposure, especially with negative UCx. Additionally, labeling patients with a history of UTI may result in repeated testing and inappropriate Abx treatment for subsequent febrile illnesses
Baseline Conditions: Between 01/01/22 to 06/01/22, 53% of patients started on Abx for a suspected UTI had a negative UCx (n=575). 2/575 with positive UCx were not initially prescribed Abx, but later received proper therapy upon callback; 1/575 had a return visit with positive UCx after presenting to the UC at least 5 days prior. Around 60 callbacks per month were made to stop Abx. Not all families were reached, leading to potential Abx misuse and resistance. Our aim: By December 2023 to reduce the percentage (%) of children over 2 years started on Abx and discharged with a UTI diagnosis with negative UCx from 53% to 25%.

Design/Methods: Interventions included education on UTI screening, interpreting UA and developing a UTI algorithm, EMR reminders, group, and individual feedback sessions. The outcome measure: The % of children meeting inclusion criteria initiated on Abx for UTI, but having a negative UCx. Balancing measures: Positive UCx and no initial Abx prescription and those returning with positive UCx that had presented to the UC at least 5 days prior. While we are aware UTI definition is likely to evolve with emerging data, we defined UTI per 2011 AAP guidelines (pyuria and Ucx >50,000 cfu/ml single uropathogen) irrespective of UA collection technique. Control charts were used to analyze data.

Results: Throughout the intervention period, 1494 children were diagnosed with a UTI. The % of children with negative UCx receiving Abx decreased to 46% from 53% with a special cause variation observed (figure 1). Notably, < 2% of children with positive UCx were not initially prescribed Abx, but later received proper therapy upon callback; only 10/800 returning after 5 days had a positive UCx, not statistically significant.

Conclusion/Discussion: Considering rising Abx resistance, cautious Abx prescribing is crucial. Refining UA collection technique and empirical treatment are needed, as UTIs are commonly diagnosed before the UCx results. Despite not reaching our goal of 25%, our study reduced inappropriate Abx use by improving UA collection quality and sample interpretation. Providers critically evaluated UA results before starting Abx, formulated empiric Abx start criteria, and minimized the need for Abx stoppage calls. Our study highlights the challenges in standardizing UTI guidelines and interpreting tests across many variables.