Improving Antibiotic Prescribing for Children With Urinary Tract Infection in Emergency and Urgent Care Settings

Abstract

Objectives Children with urinary tract infection (UTI) are often diagnosed in emergency and urgent care settings and increasingly are unnecessarily treated with broad-spectrum antibiotics. This study evaluated the effect of a quality improvement intervention on empiric antibiotic prescribing for the treatment of uncomplicated UTI in children. Methods A local clinical pathway for uncomplicated UTI, introduced in June 2010, recommended empiric treatment with cephalexin, a narrow-spectrum (first-generation) cephalosporin antibiotic. A retrospective quasi-experimental study of pediatric patients older than 1 month presenting to emergency and urgent care settings from January 1, 2009, to December 31, 2014, with uncomplicated UTI was conducted. Hospitalized patients and those with chronic conditions or urogenital abnormalities were excluded. Control charts and interrupted time-series analysis were used to analyze the primary outcome of narrow-spectrum antibiotic prescribing rates and the balancing measures of 72-hour revisits, resistant bacterial isolates, and subsequent inpatient admissions for UTI. Results A total of 2134 patients were included. There was an immediate and sustained significant increase in cephalexin prescribing before (19.2%) versus after (79.6%) pathway implementation and a concurrent significant decline in oral third-generation cephalosporin (cefixime) prescribing from 50.3% to 4.0%. There was no significant increase in 72-hour revisits, resistant bacterial isolates, or inpatient admissions for UTI. Conclusions A clinical pathway produced a significant and sustained increase in narrow-spectrum empiric antibiotic prescribing for pediatric UTI. Increased empiric cephalexin prescribing did not result in increased treatment failures or adverse patient outcomes. Future studies on implementing clinical pathways for children outside a pediatric hospital network are needed.

Association of Antibiotic Treatment Duration With Recurrence of Uncomplicated Urinary Tract Infection in Pediatric Patients

“…However, it is possible that the slightly lower rates we observed in part reflect improved practice models and implementation of antibiotic stewardship interventions. 6,24,25…”

“…Although definitive antimicrobial therapy should be guided by results from urine cultures and sensitivities, establishing clinical UTI treatment pathways to direct selection of empirical antibiotics, based on factors such as prior antibiotic use and local resistance patterns, may contribute to more appropriate antibiotic selection and reduced rates of recurrence. 24…”

“…However, it is possible that the slightly lower rates we observed in part reflect improved practice models and implementation of antibiotic stewardship interventions. 6,24,25 With respect to pharmacotherapy, nitrofurantoin is known to be ineffective for treatment of pyelonephritis because of insufficient tissue concentrations 25 ; thus, the more than 3.5-fold increase in odds of recurrence that was associated with the interaction of a pyelonephritis diagnosis with nitrofurantoin use was expected. However, it is notable that the combination of parenteral and oral cephalosporin was associated with the highest relapse and reinfection rates (12.7% and 4.3%, respectively) of all regimens studied (P < 0.01).…”

Analysis of Community-Acquired Urinary Tract Infection Treatment in Pediatric Patients Requiring Hospitalization: Opportunity for Use of Narrower Spectrum Antibiotics

“…5,7 First-generation cephalosporins (FGCs) have been used for UTI treatment in various settings. 10-12 They would be considered more narrow than TGC for UTI pathogens (eg, Eschericia coli, Klebsiella spp, Enterobacter spp), while providing additional empiric coverage compared with aminopenicillins and trimethoprim/sulfamethoxazole (TMP/SMX). 7,13,14 For empiric treatment decisions among admitted patients with a UTI, factors associated with differences in coverage between FGC and TGC could help stratify empiric treatment decisions and increase utilization of a narrow-spectrum antibiotic.…”

Reducing Antibiotic Prescription Errors in the Emergency Department: A Quality Improvement Initiative

“…Clinical pathways for common pediatric infections often recommend the selection of appropriate antibiotics for outpatient care. 18 Antibiotic selection to treat common pediatric infections, including UTI and SSTI, should be guided by local antibiotic resistance patterns and focus on the use of narrow-spectrum antibiotics. Poole et al 18 demonstrated that a clinical pathway for UTI improved narrow-spectrum prescribing for UTIs discharged from the ED and urgent care settings.…”