LO91: Urinary tract infections in the paediatric emergency department: A quality improvement initiative to promote diagnostic and antimicrobial stewardship

Abstract

Background: Urinary tract infection (UTI) is a common diagnosis in children presenting to the Emergency Department (ED) and often leads to empiric antibiotic treatment prior to culture results. A recent study at our centre found that 47% of children diagnosed with a UTI and discharged on antibiotics had a negative urine culture. None of these patients were notified of the negative result or to discontinue antimicrobial treatment. Aim Statement: The aim of this study was to improve UTI diagnostic accuracy by 50% while promoting antimicrobial stewardship through timely antibiotic discontinuation and standardized antimicrobial treatment for uncomplicated UTIs over the next 12 months. Measures & Design: Three interventions were developed using plan-do-study-act (PDSA) cycles. In collaboration with the hospital's Choosing Wisely campaign and antimicrobial stewardship program, an evidence-based empiric UTI diagnostic algorithm was created to aid with diagnostic decision-making and reduce practice variation. A daily call-back system was also implemented for urine cultures where patients who had a negative urine culture were contacted to stop antibiotics. Lastly, a practice alert was integrated in the EMR as a reminder of appropriate antimicrobial prescription duration. The main outcome measures were the percentage of inappropriately diagnosed UTIs and percentage with timely antimicrobial discontinuation. Process measures included antibiotic days saved, treatment duration, and physician adherence to the algorithm. As a balancing measure, positive urine cultures were reviewed to assess accuracy of the algorithm to detect UTIs and potential harm from delayed UTI diagnoses. Evaluation/Results: Early results from the 530 children included in the analysis demonstrated a 14% reduction in inappropriate UTI diagnoses. With the initiation of the call-back system, the antibiotic days saved increased from 0 to 495 days. Call-backs for negative cultures increased from 0% to 68% of the time. Of those positive cultures with a missed UTI diagnosis, only 5 patients in 5 months had a return visit within 72 hours and none required admission. Discussion/Impact: Appropriate diagnosis and treatment of UTIs in our ED has improved with the implementation of a diagnostic algorithm. A larger impact is anticipated once the algorithm is embedded in the EMR as a form of decision support, but these changes take time to implement. Although labour intensive, the call-back system has greatly impacted the antimicrobial days saved and reduced risk for harm in this population.