Decreasing Antibiotic Duration for Uncomplicated Urinary Tract Infection in Pediatric Emergency Department

Purpose/Objectives: Uncomplicated UTI (uUTI) is defined as any UTI without fever, systemic symptoms, back pain/tenderness and/ or complex renal, urological or neurological conditions. Evidence suggests that in children >24 months of age with uUTI, 3-5 days of antibiotic treatment is equivalent to longer duration. Shorter duration may reduce resistance, adverse effects & noncompliance. Although multiple international guidelines (UK NICE guidelines, European Consensus Guidelines, and Australian National guidelines) recommend 2-5 days of antibiotics for uUTI, there are no guidelines in the US for antibiotic duration for uUTI in this age group.
At baseline, only 9% of 5-18 year old patients discharged from our tertiary healthcare system’s 3 emergency departments (EDs) from 07/01/20 to 01/06/21 with a diagnosis of uUTI (n = 360) got ≤5 days antibiotics.

Aim: To increase the proportion of children 5-18 years of age discharged from our EDs for uUTI given shorter duration (defined as ≤5 day) of antibiotic prescriptions from 9% to >50% by December 2021.

Design/Methods: Interventions included education on evidence for shorter duration, individual performance feedback, periodic reminders, and electronic medical record changes. The outcome measure was percentage of children treated for uUTI with antibiotic duration ≤5 days. Antibiotic days saved were calculated as the difference between total antibiotic days in the intervention phase and expected antibiotic days without the QI interventions. Revisits for UTI symptoms within 14 days of the index visit were monitored as balancing measure. Run charts were used to analyze data using standard rules for centerline shift.

Results: 264 patients were treated for uUTI in the intervention period from 01/13/21 to 06/30/21. Median percentage of patients getting shorter antibiotic duration for uUTI increased from 9% (33/360) to 70.5% (191/264), with goal (>50%) met within 2 months. Special cause variation was observed with 12 consecutive data points above baseline signifying a centerline shift (Figure 1). A total of 651 antibiotic days were saved. One out of 73 patients with culture positive uUTI treated with ≤ 5 days of antibiotics returned within 14 days with uUTI.

Conclusion/Discussion: We increased median percentage of shorter antibiotic duration prescriptions for uUTI from 9% to 70.5%, saving 651 days antibiotic exposure, and only one patient returning for a diagnosis of uUTI.
Given rapid increase in shorter antibiotic duration, we plan to set a higher goal in terms of: (1) reduce lower limit of eligible patients to 2 years, or (2) consider even shorter duration of antibiotics ( <3 days). Both are supported by evidence. To achieve further improvement, we plan an Electronic Medical Record change to make short duration as the default order for uUTI treatment.