349 Utilization of an Antibiogram and a Pathway for Urinary Tract Infections in a Pediatric Emergency Department to Improve Empiric Antimicrobial Treatment: A Quality Improvement Project

Abstract

Escherichia coli is the most common cause of pediatric urinary tract infections (UTI). Antimicrobial resistance including extended spectrum beta-lactamase (ESBL) has increased alarmingly since the early 2000s, leaving antibiotics such as penicillins and cephalosporins ineffective. Overutilization of third generation cephalosporins (3GC) can add selective pressure and serve as a risk factor for development of an ESBL infection. An antibiotic review at our institution demonstrated children with community-acquired UTIs were receiving a 3GC as a part of treatment from the emergency department (ED). A UTI-specific antibiogram demonstrated good susceptibility to first generation cephalosporins (1GC). Our primary objective was to provide education based on our antibiogram and implement a UTI pathway in the ED to decrease the overall use of 3GC while maintaining clinical outcomes. This was a prospective study in a freestanding urban academic pediatric medical system consisting of an ED with an annual census of 60, 000 patients (Site A) as well as a small satellite non-academic campus ED (Site B). Data was collected from July 2019 to June 2020 and included patients 60 days to 18 years of age with a positive urine culture and a diagnosis of UTI who were discharged from the ED, excluding those with concurrent urologic conditions and non-UTI infections. Data was collected pre-implementation (July 2019 - October 2019) and post-implementation (December 2019 - June 2020) of our interventions at Site A. (See Figure 1) Interventions included provider huddles, education, and pathway implementation. Site B acted as a control group where the pathway was available but the education and provider huddles were not implemented. The primary outcome was comparing the frequency that the proposed empiric treatment pathway was followed pre- and post-interventions, and was analyzed using the Binomial Test. The secondary outcome was comparing the antibiotic treatment days, and was analyzed using the Mann-Whitney U Test. 309 pediatric patient encounters (194 from Site A and 115 from Site B) were included; 122 pre- and 187 post-intervention. 286 (93%) were female, and 139 (45%) were Caucasian. Mean age (years) was 6.86 (range 0.2-18). 271 (87%) urine cultures grew E. coli. Of all gram-negative pathogens isolated, 88% were susceptible to 1GC. For Site A, the correct drug based on pathway was improved from 36% to 69.2% post-intervention (p = <0.001) with a median of 81%. Median duration of antimicrobial therapy at Site A pre-intervention was 11 days and post-intervention was 10 days (p = 0.004). Site B showed no change in correct drug or duration. The most common initial antibiotic prescribed at Site A was 3GC (59%) pre-intervention and 1GC (60%) post-intervention. 3GC was most common at Site B both pre- (72%) and post-intervention (55%). Our data demonstrates that a pathway alone will not change practice. Education at different levels (attendings and trainees) and provider huddles along with a pathway improved antimicrobial prescribing patterns in pediatric patients with a community-acquired UTI. Overall, this study is generalizable to other populations and will be expanded to include other clinical settings in an effort to continue improving antimicrobial usage in children.