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Urinary Tract Infection and Antimicrobial Stewardship in the Emergency Department
Insights
Empiric antibiotic use for suspected urinary tract infections (UTIs) in the emergency department (ED) often leads to unnecessary antibiotic exposure. Many diagnosed UTIs are not confirmed by urine culture results, indicating a need for improved antimicrobial stewardship.
Area of Science:
- Pediatric Emergency Medicine
- Infectious Diseases
- Antimicrobial Stewardship
Background:
- Urinary tract infections (UTIs) are common in children presenting to the emergency department (ED).
- Empiric antibiotic therapy is frequently initiated based on presumed UTI diagnosis.
- The confirmation rate of UTI by urine culture after ED discharge is not well-established.
Purpose of the Study:
- To evaluate the accuracy of empiric antibiotic prescribing for presumed UTIs in the pediatric ED.
- To determine the proportion of patients whose urine cultures do not confirm a UTI diagnosis after receiving antibiotics.
- To identify opportunities for enhancing antimicrobial stewardship in pediatric UTI management.
Main Methods:
- Retrospective cohort study of patients aged 21 years or younger in a pediatric ED.
- Inclusion criteria: urinalysis, urine culture, and discharge with empiric antibiotics for presumed UTI.
- Exclusion criteria: known urinary tract anomaly or recent antibiotic use.
- Confirmed UTI definition: pyuria and ≥50,000 CFU/mL of a uropathogen.
Main Results:
- Of 175 patients, only 51% had a confirmed UTI based on pyuria and positive urine culture.
- Pyuria was present in 94% of patients, but only 55% had a positive urine culture.
- Commonly prescribed antibiotics included cefdinir (59%) and trimethoprim/sulfamethoxazole (23%).
- Median antibiotic duration was 10 days, negatively correlated with patient age.
Conclusions:
- Current empiric antibiotic prescribing for suspected UTIs in the ED leads to significant unnecessary antibiotic exposure.
- A substantial number of patients receive antibiotics for infections not subsequently confirmed by urine culture.
- There is a critical need for improved outpatient antimicrobial stewardship to optimize UTI treatment in pediatric ED settings.
Objectives:
The aims of this study were to assess empiric antibiotic use for presumed urinary tract infection (UTI) in the emergency department (ED) and to determine how often urine culture results subsequently do not confirm the diagnosis.
Methods:
This study is a retrospective cohort study of patients aged 21 years or younger in the Nationwide Children's Hospital ED from May 1, 2012, to October 31, 2012, who had a urinalysis and urine culture performed and were discharged home with empiric antibiotic therapy for presumed UTI. Patients with known urinary tract anomaly or antibiotic use in the previous 7 days were excluded. Confirmed UTI was defined as pyuria (>5 white blood cells per high-power field or dipstick positive for leukocyte esterase) and a positive urine culture (≥50,000 colony-forming units/mL of a uropathogen).
Results:
Of the 175 enrolled patients, urine was obtained by clean catch in 138 (79%), catheterization in 35 (20%), first-pass void in 1 (0.6%), and undocumented method in 1 (0.6%). Pyuria was demonstrated in 164 patients (94%), but only 97 (55%) had a positive urine culture. The combination of pyuria and a positive urine culture confirmed UTI in 90 patients (51%). The most commonly prescribed antibiotics were cefdinir in 103 patients (59%), trimethoprim/sulfamethoxazole in 40 (23%), and ciprofloxacin in 23 (13%). The median duration of prescribed therapy was 10 days (interquartile range, 7-10 days). Treatment duration was correlated negatively with age (r = -0.53, P < 0.01).
Conclusions:
The current management of suspected UTI in ED patients results in unnecessary antibiotic exposure, highlighting an important opportunity for outpatient antimicrobial stewardship efforts.
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