Opportunities for Antibiotic Reduction in Pediatric Patients With Urinary Tract Infection After Discharge From the Emergency Department

Objectives: The aim of this study was to evaluate how often antibiotics are adjusted by providers, specifically discontinued or de-escalated to a more narrow-spectrum agent, based on final culture and susceptibility results, when treating patients diagnosed with a urinary tract infection (UTI) in the pediatric emergency department (ED). Methods: This was a retrospective study of pediatric patients younger than 18 years who were discharged home from the ED with a diagnosis of UTI between January 1, 2018, and December 31, 2019. Patients were included if a urine culture was sent as part of their UTI workup and were excluded if they had been pretreated with antibiotics before the diagnosis. Discontinuation was considered possible if the urine culture had no or insignificant bacterial growth. De-escalation was defined as changing to a more narrow-spectrum antibiotic based on susceptibility testing. Results: Empiric antibiotics were prescribed in 131 of 136 UTI episodes. Cefdinir (39%) and cephalexin (36%) were most commonly prescribed, but agents and durations were inconsistent. Discontinuation occurred in only 4 of 52 possible episodes (8%), resulting in a median of 6 extra days of unnecessary antibiotics per episode. For 62 of the 78 cases (79%) with culture confirmation, the prescribed empiric antibiotic was active against the isolated pathogen. A narrower agent could have been used in 29 of 62 (47%) of these cases. However, de-escalation was never attempted. Lack of de-escalation in these episodes resulted in a median of 7 extra days of unnecessary broad-spectrum antibiotic exposure. Conclusions: Inconsistent empiric antibiotics and inaccurate diagnosis result in excess antibiotic exposures for pediatric patients diagnosed with UTI. Postdischarge antimicrobial stewardship interventions are needed to reduce unnecessary antibiotic exposure in children.