Decreasing Misdiagnoses of Urinary Tract Infections in a Pediatric Emergency Department
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Published on: December 4, 2020
Olivia Ostrow1,2, Michael Prodanuk3,2, Yen Foong3,2
1Division of Pediatric Emergency Medicine, Department of Pediatrics.
Insights
A new electronic diagnostic tool and callback system significantly reduced misdiagnosed urinary tract infections (UTIs) in children. This initiative improved antibiotic stewardship in the emergency department by decreasing unnecessary antibiotic prescriptions.
Area of Science:
- Pediatric Emergency Medicine
- Clinical Informatics
- Antimicrobial Stewardship
Background:
- Urinary tract infections (UTIs) are common in emergency departments (EDs), frequently treated empirically with antibiotics before culture results are available.
- Accurate diagnosis of UTIs, especially in pediatric patients, presents challenges, leading to common misdiagnoses.
- An initiative aimed to halve misdiagnosed uncomplicated pediatric UTIs and enhance antimicrobial stewardship in the ED over four years.
Purpose of the Study:
- To decrease the misdiagnosis rate of uncomplicated pediatric urinary tract infections (UTIs) by 50%.
- To improve antimicrobial stewardship within the emergency department setting.
- To implement and sustain interventions over a 4-year period.
Main Methods:
- The Model for Improvement framework guided the development of three key interventions: an electronic UTI diagnostic algorithm, a callback system, and standardized antibiotic prescriptions for discharge.
- Outcome measures focused on the reduction in UTI misdiagnosis (defined as antibiotic prescription with negative urine culture) and the number of antibiotic days saved.
- Balancing measures included monitoring return visits or hospitalizations for patients with positive urine cultures but no UTI diagnosis, analyzed using statistical process control and run charts.
Main Results:
- The mean rate of UTI misdiagnosis significantly decreased from 54.6% to 26.4% between 2017 and 2021.
- Adherence to standardized antibiotic durations improved substantially, rising from 45.1% to 84.6%.
- The callback system facilitated antibiotic days saved, with 2128 days saved and 89% of patients with negative cultures contacted to discontinue antibiotics; only 14 of 186 patients with positive cultures and unremarkable urinalysis returned to the ED, with 2 hospitalizations.
Conclusions:
- The integration of a UTI diagnostic algorithm with a callback system effectively and safely reduced both misdiagnoses and antibiotic consumption.
- Electronic implementation as a decision support tool, complemented by audit, feedback, reminders, and education, proved crucial for the long-term sustainability of these interventions.
Background And Objectives:
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.
Methods:
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.
Results:
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.
Conclusions:
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.
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