Decreasing Misdiagnoses of Urinary Tract Infections in a Pediatric Emergency Department

Urinary tract infection (UTI) is a common diagnosis in the emergency department (ED), often resulting in empirical antibiotic treatment before culture results. Diagnosis of a UTI, particularly in children, can be challenging and misdiagnosis is common. The aim of this initiative was to decrease the misdiagnosis of uncomplicated pediatric UTIs by 50% while improving antimicrobial stewardship in the ED over 4 years.

By using the Model for Improvement, 3 interventions were developed: (1) an electronic UTI diagnostic algorithm, (2) a callback system, and (3) a standardized discharge antibiotic prescription. Outcome measures included the percentage of patients with UTI misdiagnosis (prescribed antibiotics, but urine culture results negative) and antibiotic days saved. As a balancing measure, positive urine culture results without a UTI diagnosis were reviewed for ED return visits or hospitalization. Statistical process control and run charts were used for analysis.

From 2017 to 2021, the mean UTI misdiagnosis decreased from 54.6% to 26.4%. The adherence to the standardized antibiotic duration improved from 45.1% to 84.6%. With the callback system, 2128 antibiotic days were saved with a median of 89% of patients with negative culture results contacted to discontinue antibiotics. Of 186 patients with positive urine culture results with an unremarkable urinalysis, 14 returned to the ED, and 2 were hospitalized for multiresistant organism UTI treatment.

A UTI diagnostic algorithm coupled with a callback system safely reduced UTI misdiagnoses and antibiotic usage. Embedding these interventions electronically as a decision support tool, targeted audit and feedback, reminders, and education all supported long-term sustainability.