P2B033: Changes in Emergency Department Antibiotic Prescribing for Pediatric Urinary Tract Infections, 2011-2020

Background: Urinary tract infections (UTIs) are among the most common pediatric infections requiring antibiotic use in children. Antibiotic selection has become challenging over time as providers balance concerns for resistant pathogens with antibiotic stewardship efforts. Prior studies of national antibiotic prescribing practices for pediatric UTIs demonstrated that use of third-generation cephalosporins, a broad-spectrum class for these infections, doubled from 1998 to 2007. More recently, updated susceptibility criteria for Escherichia coli, which causes most UTIs, have clarified that first-generation cephalosporins—a preferred option due to their relatively narrow spectrum—provide reliable empiric therapy for pediatric UTIs. To assess whether this change has affected clinical practice, we investigated national antibiotic prescribing patterns in emergency department (ED) visits over a recent 10-year period.

Methods: We performed a retrospective cross-sectional analysis of the 2011-2020 National Hospital Ambulatory Medical Care Surveys (NHAMCS), a multi-stage probability sample survey that collects information on emergency care services based on a sample of hospital visits nationally. We included children < 18 years of age who presented to the ED with a diagnosis of UTI, as defined by diagnosis codes. Over two-year intervals across the study period, we assessed changes in prescribing patterns for common enteral options for UTIs: trimethoprim-sulfamethoxazole (TMP-SMX), first-generation cephalosporins, and third-generation cephalosporins. Three multivariable logistic regressions were performed, one for each treatment option, to adjust for potential confounders including age, sex, race/ethnicity, visit payment method, fever at presentation, geographic region of hospital, and subsequent hospital admission. We used SAS 9.4 survey procedures to account for the complex sampling design; we present weighted results to reflect national estimates.

Results: A total of 1,083 children were included in our study, representing an estimated 6.9 million ED visits for pediatric UTI. Demographic and visit characteristics remained similar across the study period. Over the 10-year period, the national estimated percentage of UTI visits where first-generation cephalosporins were prescribed more than doubled, while the percentage halved for TMP-SMX, and was largely unchanged for third-generation cephalosporins (Figure).

Adjusting for the previously described covariates, each 2-year time interval increase was associated with an adjusted odds ratio (aOR) of 0.81 (95% CI 0.70-0.94) for TMP-SMX prescription receipt (p=.0049) and an aOR of 1.32 (95% CI 1.11-1.57) for first-generation cephalosporin prescription receipt (p=.0014) (Table). The aOR for third-generation cephalosporin prescription receipt was 0.99 (95% CI 0.86-1.15) for each two-year time interval increase (p=.94).

Conclusion: Prescribing practices for pediatric UTI in the ED setting have changed significantly from 2011 to 2020 among a nationally representative sample, with decreased odds of TMP-SMX and increased odds of first-generation cephalosporin use. This study suggests that nationally, ED providers are responding to evolving understanding of E. coli susceptibility patterns, as well as stewardship concerns. However, third-generation cephalosporin use showed no significant change.