1357 - Urinary Symptom Management in Children with Neuropathic Bladder Presenting to the Emergency Department

Background: Children with neuropathic bladders are at high risk for developing urinary tract infections (UTIs). The accurate diagnosis of UTI is complicated by altered sensation and the ubiquity of bacterial colonization. As a result, overdiagnosis and overtreatment for presumed UTIs is common. The objective of this study is to estimate potential overdiagnosis and unnecessary antibiotic treatment in children with neuropathic bladder presenting to the Emergency Department (ED) with urinary symptoms.

Methods: Retrospective cohort study of patients with neuropathic bladder presenting to the Children’s National Hospital ED between October 2008 and December 2019. Chart review was used to determine presenting symptoms, urinary evaluation, and antibiotic treatment. We used the validated urinary symptoms questionnaire (USQNB-IC) to categorize ED visits as 'evaluation warranted' if the patient presented with at least one of the actionable symptoms on the USQNB-IC. We used the Spina Bifida Association’s (SBA) published definitions for UTI to determine which patients warranted presumptive antibiotic treatment.

Results: There were 211 visits by 82 patients (43% female), with a mean of 4.6 visits per patient (IQR 6). Mean age at ED visit was 5.2 years (SD 4.2 years). The most common presenting symptoms were fever (57%), emesis (32%), abdominal pain (24%), foul-smelling urine (11%), and cloudy urine (8%). Of the total visits, 122 (58%) had a urinary evaluation and 31% were treated with antibiotics. Sixteen ED visits (8%) resulted in a urinary evaluation that was not warranted. Of the 122 ED visits with urinary evaluation, 32 patients (26%) did not meet SBA criteria for UTI but were treated empirically with antibiotics.Table 1: Urinary evaluation in children with neuropathic bladder seen in CNH ED between October 2008 and December 2019.
Table 2: UTI treatment in children with neuropathic bladder seen in CNH ED between October 2008 and December 2019.


Conclusion: Most children with neuropathic bladder presenting to the ED were appropriately evaluated and treated for presumed UTI. One-quarter of evaluated children received empiric antibiotics despite not meeting SBA criteria for UTI, indicating this may be a target for educational initiatives to promote antibiotic stewardship.  Further research is needed to generate and validate clinical guidelines for emergency department providers to limit unnecessary testing and antibiotic therapy in this population.