Uncomplicated Urinary Tract Infection in Ambulatory Primary Care Pediatrics: Are We Using Antibiotics Appropriately?

Abstract

OBJECTIVES Antimicrobial stewardship programs target antimicrobial use within the inpatient care setting. However, most antimicrobials are prescribed at ambulatory sites. We aim to determine the appropriateness of the diagnosis and treatment of uncomplicated urinary tract infection (UTI) in children within the outpatient setting at our institution, and to evaluate the cost of antibiotic treatment in our patient cohort. METHODS This retrospective study was conducted by reviewing electronic records of patients aged 2 to 18 years diagnosed with uncomplicated UTI and treated with antibiotics in the outpatient setting from January 1, 2016, to April 30, 2016. Appropriate diagnosis was defined as confirmed UTI that included: pyuria (>5 white blood cells per high-power field or positive for leukocyte esterase), a positive urine culture (≥50,000 colony units/mL of a single uropathogen for a catheterized sample or ≥100,000 colony units/mL for a clean catch urine sample), and lower urinary tract symptoms. Treatment was considered appropriate if the patient was prescribed first-line antibiotic for the susceptible isolate (trimethoprim sulfamethoxazole, amoxicillinclavulanate, nitrofurantoin, and cephalexin), and if the appropriate dose was used. RESULTS We included 178 patients receiving a diagnosis of uncomplicated UTI and treated with antibiotics. Of these, 70% received an inappropriate diagnosis (n = 125). 58% (n= 72) of improperly diagnosed patients had polymicrobial growth in their urine cultures. Antibiotics prescribed mostly in this group were trimethoprim-sulfamethoxazole (53%, n = 66) and cephalexin (22%, n = 27). Only 30% of all included patients received an appropriate diagnosis (n = 53). Of all appropriate diagnosis patients (n = 53), 26% were treated inappropriately (n = 14) with either wide-spectrum antibiotics (n = 8) or with low calculated dose (n = 6). The estimated cost of antibiotic treatment for the inappropriate diagnosis group (n = 125) was $10,755.87. CONCLUSION Antimicrobial stewardship programs should target the pediatric outpatient setting and antibiograms should be developed. Education of providers about the appropriate diagnosis and treatment of uncomplicated UTI in children is essential for reducing the cost of inappropriate therapy.

Appropriateness of Antibiotic Prescriptions for Urinary Tract Infections

“…10 Prescribing practices for UTIs are variable and problems exist, including the use of overly broad antibiotics and treatment in the absence of true infection. 11,12 To investigate antibiotic prescribing practices for suspected UTIs, we primarily sought to determine whether empiric antibiotic selection was appropriate for suspected UTIs in children and adults. Secondarily, we set out to analyze frequency of antibiotic prescription in the absence of true infection and whether variation in appropriate antibiotic selection existed between specific provider groups, including attending physicians, resident physicians, physician assistants, and nurse practitioners.…”

<p>Pediatric Antimicrobial Stewardship Programs: Current Perspectives</p>

“…Diagnoses frequently encountered in the outpatient setting categorized as "low-hanging fruit" ripe for outpatient AS interventions include acute otitis media (AOM), pharyngitis, acute bacterial sinusitis, skin and soft-tissue infections, community-acquired pneumonia, and urinary tract infections. [77][78][79][80][81] Macrolides and third-generation oral cephalosporins like cefdinir are often prescribed inappropriately as first-line agents for treatment of pharyngitis and communityacquired pneumonia. 78,80,82 In one study conducted within a single large US healthcare system, pediatricians were more likely than advanced practice providers and non-pediatricians to have: 1) prescribed antibiotics for pediatric sinusitis that were concordant with national guidelines and 2) appropriately withheld antibiotics when upper respiratory infections were diagnosed.…”

Pyuria without Casts and Bilateral Kidney Enlargement Are Probable Hallmarks of Severe Acute Kidney Injury Induced by Acute Pyelonephritis: A Case Report and Literature Review

“…The analysis of available data showed that the incidence of oligoanuria was 46.1% in the T-group and 52.5% in the H-group. The rates of pyuria, which was defined as a urine WBC count of >5/high-power field or dipstick positivity for leukocyte esterase ( 25 ), and the absence of pathologic casts were 73.0%/78.9% in the T-group and 57.6%/68.4% in the H-group, respectively. The incidence of bilateral kidney enlargement on imaging was 61.5% in the T-group and 68.4% in the H-group.…”