P3.276: Improving Antibiotic Stewardship in Suspected Pediatric Urinary Tract Infections: A Quality Improvement Project

Purpose/Objectives: Urinary tract infections (UTIs) are one of the most common indications for antibiotics in pediatric patients presenting to the Emergency Department (ED). However, accurate diagnosis requires a urine culture which can take 24+ hours to result, leading to empiric antibiotics prescriptions. At this institution there is not a formal process for following up on negative cultures. The primary aim of this Quality Improvement (QI) project is to improve management of pediatric patients by discontinuing 80% of antibiotics prescribed to those with subsequent negative urine cultures. Secondary aims are to align pediatric UTI diagnosis and management with evidence-based recommendations.

Design/Methods: This multidisciplinary QI project follows the Model for Improvement framework with Plan-Do-Study-Act cycles. We identified pediatric UTI cases (ages 2 months – 18 years) who were diagnosed with a UTI in the ED. Outcomes of suspected UTIs were categorized as confirmed, unknown, or negated. A confirmed UTI required single species growth exceeding 50,000 cfu/mL; UTI was negated when growth was < 10,000 cfu/mL. Within the negated UTIs, 3 cultures grew >100,000 cfu/mL of S. epidermidis or S. haemolyticus and were labeled as contaminants. Unknown cases included those without cultures completed, polymicrobial growth, or growth between 10,000-50,000 cfu/mL. The baseline data was collected from January 1 – December 31, 2023. Root cause analysis was performed with subsequent plans for all negative urine cultures to be reviewed and followed up by Pediatric Infectious Disease (PID) service, along with instituting several education initiatives by March 1, 2024. Post-intervention assessments were performed in December 2024 with changes including re-educating clinicians and reinforcing laboratory technicians sending negative cultures for review.

Results: Table 1 shows collected results since project initiation through February 28, 2025. Discontinuation of unnecessary antibiotics rose from 11 to 32% (p=0.019), but still below our goal of 80%. Post-intervention the odds ratio of discontinuing antibiotics in negated UTI cases was 3.74 (1.18-11.9). Culture data is absent in nearly 20% of suspected UTIs, accounting for >50% of unknown cases. In confirmed UTIs, 9 cases had unnecessarily broad antibiotics continued. The most prescribed antibiotics were cefdinir (44%) followed by cephalexin (31%). PCM follow-up continues to have a positive association with improved antimicrobial adjustment.

Conclusion/Discussion: Antibiotic discontinuation rates in patients with negated UTIs have significantly increased with the implemented interventions, however we have not reached our goal. Contributing factors include limitations in logistical support to flag negative cultures, and inconsistencies contacting families following ED discharge. The low rate of confirmed UTIs suggests there may be a role for diagnostic stewardship, including consistent collection of urine cultures. Broad spectrum antibiotics are commonly prescribed despite the first-line recommendation being cephalexin. Future interventions include integrating clinic nurses into antibiotic discontinuation when contacting families for ER follow-ups, and shifting empiric antibiotics to narrower spectrum.