100 - Less is More: Prescription Pause to Enhance Antibiotic Stewardship for Negative Pediatric UTI Cultures

Publication Number: 100.5785

Peter S.. Kieffer, Southern Illinois University School of Medicine, Springfield, IL, United States; Aysha Rafaquat, Southern Illinois University School Of Medicine, Springfield, IL, United States; Ezzeldin Saleh, Southern Illinois University School of Medicine, Springfield, IL, United States; Marcela Rodriguez, Southern Illinois University School of Medicine, Springfield, IL, United States; Archana Jasti, Currently looking for job, Hoover, AL, United States; Hannah Schmidt, Southern Illinois University School of Medicine, Springfield, IL, United States

Background: Pediatric patients discharged from the Emergency Department (ED) diagnosed with urinary tract infection (UTI) often take antibiotics unnecessarily for several days. ED Quality Assurance (QA) protocols typically focus on positive untreated cultures. We identified in our ED that no structured process exists to communicate negative culture results and discontinue antibiotics when appropriate, which could potentially save hundreds of antibiotic days

Objective: Our objective was to implement antimicrobial stewardship (ASP) initiative in pediatric ED setting to monitor and respond promptly to negative urine cultures and discontinue antibiotics prescribed for presumptive UTI when appropriate, thereby reducing unnecessary antibiotic use.

Design/Methods: We conducted a quality improvement (QI) study in our Pediatric ED. We included children < 18 years seen between May 2021 and July 2024 who were treated for presumptive UTI and had subsequent negative urine-culture. We designed and deployed an automated daily report of negative urine cultures (no growth or ≤ 1,000 CFU/ml) harvested from the electronic medical record (EMR). We assessed the appropriateness of continued antibiotics based on clinical data, ED exam, urinalysis, and relevant tests, and contacted families to discuss discontinuation when appropriate. We calculated the total antibiotic days saved (ADS); defined as the difference between the number of days prescribed and days of antibiotics already taken. Our counterbalancing measure was 72-hour return to our ED or affiliated clinics.

Results: We reviewed 83 charts meeting inclusion criteria (Figure 1). Antibiotic continuation was deemed necessary for 25. 58 participants were selected for intervention. Antibiotics were discontinued in 51 presumptively treated UTI patients.Table (1) shows characteristics, presenting symptoms and urinalysis results of study participants. We had 90% success rate of contacting families for callback discussions and saved 238 antibiotic days (4.7 ADS/patient) without any 72-hour returns. Pyuria was present in 100% of patients with a mean of 14 (range 7- >182) WBC/HPF. Cephalexin was the most common antibiotic prescribed (82%), and viral gastroenteritis was the most common alternative diagnosis (47%) (Table 2)

Conclusion(s): Our ASP initiative for automated monitoring and callbacks for negative urine culture effectively and safely reduced unnecessary antibiotic days in children with presumed UTI in ED setting. Incorporating similar ASP protocols for follow-up of negative urine cultures within established ED QA programs is an invaluable opportunity to reduce unnecessary antibiotic days

Figure 1
UTI Negative Culture Call back project's inclusion criteria, the reason for antibiotic continuation in some of the study participants, and the reason for excluding some participants from the study.

Table 1
Characteristics, presenting symptoms, and urinalysis findings of Study Participants.

Table 2
The revised diagnoses table includes a variety of conditions. Most are associated with adjacent or systemic inflammation leading to sterile pyuria, with the most common alternative diagnosis being Viral Gastroenteritis.