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Antibiotic Overtreatment of Presumed Urinary Tract Infection Among Children with Spina Bifida
Victor Kucherov1, Teresa Russell1, Jacob Smith1
1Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC.
Insights
Overtreatment of urinary tract infections (UTIs) is common in children with spina bifida, often driven by pyuria without sufficient symptoms. Standardized symptom collection is crucial for accurate UTI diagnosis and treatment decisions in this population.
Area of Science:
- Pediatric Urology
- Infectious Diseases
- Clinical Informatics
Background:
- Children with spina bifida often present with non-specific symptoms that can mimic urinary tract infections (UTIs).
- Accurate diagnosis of UTIs in this population is challenging due to altered symptomatology and reliance on assisted bladder emptying.
- Overtreatment with antibiotics can lead to adverse effects and antimicrobial resistance.
Purpose of the Study:
- To identify factors contributing to the overtreatment of presumed UTIs in children with spina bifida.
- To evaluate the adherence to established UTI diagnostic criteria in this specific patient group.
- To inform clinical practice guidelines for UTI management in pediatric spina bifida patients.
Main Methods:
- Retrospective review of 236 emergency department encounters for children with spina bifida (age <21 years) requiring assisted bladder emptying.
- Analysis of urinalysis (UA) results and clinical symptoms at the time of antibiotic initiation.
- Definition of overtreatment as antibiotic administration for presumed UTI not meeting spina bifida UTI criteria (≥2 urologic symptoms + pyuria + positive urine culture).
Main Results:
- Overtreatment occurred in 80% of encounters where antibiotics were initiated (47% of the total cohort).
- The presence of pyuria with fewer than two urologic symptoms was the strongest predictor of overtreatment (OR 9.6).
- Non-Hispanic White race was associated with a reduced likelihood of overtreatment (OR 0.3).
Conclusions:
- Overtreatment of presumed UTIs is highly prevalent in children with spina bifida.
- Pyuria, often lacking specificity in this population, significantly drives overtreatment decisions.
- Standardized collection and consideration of urologic symptoms are essential for appropriate UTI diagnosis and treatment in children with spina bifida.
Objective:
To identify factors associated with overtreatment of presumed urinary tract infection (UTI) among children with spina bifida using such criteria.
Study Design:
A retrospective review of children with spina bifida (age <21 years) evaluated in the Emergency Department (ED) at a single institution was performed. Patients with a urinalysis (UA) performed who were reliant on assisted bladder emptying were included. The primary outcome was overtreatment, defined as receiving antibiotics for presumed UTI but ultimately not meeting spina bifida UTI criteria (≥2 urologic symptoms plus pyuria and urine culture growing >100k CFU/mL). The primary exposure was whether the components of the criteria available at the time of the ED visit (≥2 urologic symptoms plus pyuria) were met when antibiotics were initiated.
Results:
Among 236 ED encounters, overtreatment occurred in 80% of cases in which antibiotics were initiated (47% of the entire cohort). Pyuria with <2 urologic symptoms was the most important factor associated with overtreatment (OR 9.6). Non-Hispanic White race was associated with decreased odds of overtreatment (OR 0.3).
Conclusions:
Overtreatment of presumed UTI among patients with spina bifida was common. Pyuria, which is not specific to UTI in this population, was the main driver of overtreatment. Symptoms are a cornerstone of UTI diagnosis among children with spina bifida, should be collected in a standardized manner, and considered in a decision to treat.
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