P3B414: Antibiotic Stewardship for Negative Urine Cultures in Pediatric Emergency Department and Urgent Cares: A Quality Improvement Initiative

Purpose/Objectives: Over 1.5 million children are diagnosed with urinary tract infections (UTI) every year.1 UTI is defined as pyuria (> 5 white blood cells per high-power field or positive leukocyte esterase test on urinalysis) and a positive urine culture (> 50,000 colony forming units/mL of a uropathogen).1,2 In the emergency department (ED) or urgent care (UC), patients are discharged with antibiotics for presumed UTI based on urinalysis or urine dipstick before cultures result. In patients sent home with an antibiotic for a presumed UTI, about 50-60% will result in negative cultures and many patients will unknowingly continue antibiotics.1,3,4 Unnecessary antibiotic use precipitates antibiotic resistance and potential for adverse side effects.3,4 Goebel et al provided a framework for antibiotic stewardship for UTI in 2021 called the “Five Ds” which includes correct diagnosis, drug choice, drug dosage, duration of therapy, and de-escalation of therapy.5 Currently, our multisite pediatric center has no mechanism to de-escalate antibiotics for presumed UTI when cultures return negative.

Aims: Our goals are (1) to decrease the number of antibiotics written for UTI that result in a negative culture by 15% by July 2023 and (2) for 80% of de-escalation candidates to receive a text message notification of negative urine culture and instructions to stop antibiotics by July 2023.

Design/Methods: Our interventions include 3 components. Component A involves targeted educational interventions to standardize UTI diagnosis and management across a large provider group in ED and UC. Component B consists of a novel visualization dashboard that allows our team to track diagnoses and management of UTI (Figure 1) and institute an antibiotic de-escalation protocol (Figure 2). De-escalation candidates generated from the dashboard will be reviewed by our multidisciplinary team; if meeting all criteria for de-escalation, parent/guardian will receive a text message through the dashboard to discontinue antibiotics with updated aftercare instructions. Component C will prospectively call patients who received a text message to explore compliance and barriers; this will be discussed in a separate publication.

Results: Pre-intervention data shows 609 encounters between January-February 2023 were sent home on antibiotics with urine cultures pending. 349 encounters had a negative urine culture and did not meet exclusion criteria. 218 (62%) of these encounters were eligible for de-escalation. The average length of antibiotic course was 9 days. The dashboard will Go-Live in May 2023 and post-intervention data will be collected from May –July 2023.

Conclusion/Discussion: We believe this multi-tiered antibiotic stewardship initiative will improve care for pediatric UTI at our institution by decreasing erroneous diagnosis of UTI, overall duration of therapy, and institute a streamlined protocol for antibiotic de-escalation for negative cultures in otherwise low risk patients.