Urine Culture Follow-up and Antimicrobial Stewardship in a Pediatric Urgent Care Network

Reducing Antibiotic Duration for Uncomplicated UTI in the Pediatric Emergency Department

BACKGROUND

Short-duration (3-5 days) antibiotic treatment of uncomplicated urinary tract infection (uUTI) in children >24 months of age is equivalent to longer-duration antibiotic treatment, with added benefits of antibiotic stewardship. At our pediatric emergency department (ED), 13% of 5- to 18-year-old patients discharged with uUTI received ≤5 days of antibiotics. We aimed to increase short-duration prescriptions in patients with uUTI from 13% to >50% over 12 months.

METHODS

This quality improvement project was conducted from January 2021 to August 2022. Complicated UTI was excluded. Interventions included education, practice feedback, and electronic health record changes. The outcome measure, the proportion of children treated with a short antibiotic duration, was studied by using p-charts. Antibiotic days saved were calculated. Revisits with UTI within 14 days of confirmed uUTI treated with short-duration antibiotics (balancing measure) were analyzed by using Fisher's exact test.

RESULTS

In 1292 (n = 363 baseline, 929 post-intervention) eligible patients treated for uUTI, shorter antibiotic duration increased from 13% to 91%. We met our 50% aim within 2 months, with continued improvement leading to an additional centerline shift. Consequently, 2619 antibiotic days were saved. Two of 334 (0.6%) patients returned (P = NS) within 14 days of the index visit with a culture-positive uUTI.

CONCLUSIONS

By using education, feedback, and electronic health record changes, we decreased antibiotic duration in children discharged from the ED for uUTI without a significant increase in return visits with UTI. These interventions can be expanded to wider age groups and other outpatient settings.

Antibiotic Stewardship and Treatment of Uncomplicated Urinary Tract Infection (UTI) in Children and Adolescents in the Emergency Department of a Community Hospital

A retrospective, cross-sectional study of children with suspected urinary tract infections (UTIs) 3 months to 18 years of age who had a urinalysis and urine culture (UC) during an emergency department (ED) visit between 2019 and 2020 was performed. Chi-square, Fisher exact, and independent samples T tests were used as appropriate. Median age was 6.6 years (interquartile range = 3.3-12.4). Urinalysis positivity was 92.8%, of which 81.9% of children were prescribed a first-line antibiotic. First-line antibiotic use was 82.7%. Positive UC rate was 84.7%, with 84% receiving a first-line antibiotic (P = .025). The correlation between a positive urinalysis and a positive UC was 80.8% (P < .001). Change of antibiotics based on the uropathogen of positive UCs was 6.3% (P < .001). The urinalysis and UC guided the diagnosis and treatment of UTIs. First-line antibiotics can be safely administered in the ED and prescribed for positive urinalyses. Studies are needed to evaluate the discontinuation of antibiotics with negative UCs as part of antibiotic stewardship initiatives.

Urine soluble TLR4 levels may contribute to predict urinary tract infection in children: the UTILISE Study

BACKGROUND

One of the most common bacterial infections in childhood is urinary tract infection (UTI). Toll-like receptors (TLRs) contribute to immune response against UTI recognizing specific pathogenic agents. Our aim was to determine whether soluble TLR4 (sTLR4), soluble TLR5 (sTLR5) and interleukin 8 (IL-8) can be used as biomarkers to diagnose UTI. We also aimed to reveal the relationship between urine Heat Shock Protein 70 (uHSP70) and those biomarkers investigated in this study.

METHODS

A total of 802 children from 37 centers participated in the study. The participants (n = 282) who did not meet the inclusion criteria were excluded from the study. The remaining 520 children, including 191 patients with UTI, 178 patients with non-UTI infections, 50 children with contaminated urine samples, 26 participants with asymptomatic bacteriuria and 75 healthy controls were included in the study. Urine and serum levels of sTLR4, sTLR5 and IL-8 were measured at presentation in all patients and after antibiotic treatment in patients with UTI.

RESULTS

Urine sTLR4 was higher in the UTI group than in the other groups. UTI may be predicted using 1.28 ng/mL as cut-off for urine sTLR4 with 68% sensitivity and 65% specificity (AUC = 0.682). In the UTI group, urine sTLR4 levels were significantly higher in pyelonephritis than in cystitis (p < 0.0001). Post-treatment urine sTLR4 levels in the UTI group were significantly lower than pre-treatment values (p < 0.0001).

CONCLUSIONS

Urine sTLR4 may be used as a useful biomarker in predicting UTI and subsequent pyelonephritis in children with UTI. A higher resolution version of the Graphical abstract is available as Supplementary information.

Clinical Course of Children 1 to 24 Months Old With Positive Urine Cultures Without Pyuria

OBJECTIVE

To describe the clinical course of children with positive urine cultures without pyuria who were not given antibiotics initially, identify predictors of subsequent antibiotic treatment, and evaluate the association between subsequent treatment and urinary tract infection (UTI) within 30 days.

METHODS

We conducted a multicenter retrospective cohort study of children 1 to 24 months old who had positive urine cultures without pyuria and who were not started on antibiotics upon presentation to 3 health care systems from 2010 to 2021. Outcomes included clinical status at the time urine cultures resulted, escalation of care (emergency department visit or hospitalization) and subsequent antibiotic treatment within 7 days, and subsequent UTI within 30 days of presentation.

RESULTS

Of 202 included children, 61% were female and median age was 9 months. Of 151 patients with clinical status information when cultures resulted, 107 (70.8%, 95% confidence interval [CI] 62.9-77.9%) were improved. Two of 202 children (1.0%, 95% CI 0.2-4.0%) experienced care escalation. Antibiotics were started in 142 (82.2%) children, and treatment was associated with prior UTI (risk ratio [RR] 1.20, 95% CI 1.15-1.26) and lack of improvement (RR 1.22, 95% CI 1.13-1.33). Subsequent UTI was diagnosed in 2 of 164 (1.2%, 95% CI 0.1-4.3%) treated and 0 of 36 (0%, 95% CI 0-9.7%) untreated children.

CONCLUSIONS

Seventy percent of children with positive urine cultures without pyuria improved before starting antibiotics; however, >80% were ultimately treated. Future research should study the impact of diagnostic stewardship interventions and various urine testing strategies to optimize the management of children evaluated for UTI.retain-->.

A hidden gem in multidisciplinary antimicrobial stewardship: a systematic review on bedside nurses' activities in daily practice regarding antibiotic use

Background

Antimicrobial stewardship (AMS), the set of actions to ensure antibiotics are used appropriately, is increasingly targeted at all those involved in the antimicrobial pathway, including nurses. Several healthcare organizations have issued position statements on how bedside nurses can be involved in AMS. However, it remains unclear how nurses, in reality, contribute to appropriate antibiotic use.

Objectives

To systematically search the literature to describe the activities bedside nurses perform regarding antibiotic use in daily clinical practice, in relation to the activities proposed by the aforementioned position statements.

Methods

We searched MEDLINE, Embase, CINAHL and grey literature until March 2021. Studies were included if they described activities regarding antibiotic use performed by bedside nurses. Methodological rigour was assessed by applying the Mixed Method Appraisal Tool.

Results

A total of 118 studies were included. The majority of the proposed nurses' activities were found in daily practice, categorized into assessment of clinical status, collection of specimens, management of antimicrobial medication, prompting review and educating patient and relatives. Nurses may take the lead in these clinical processes and are communicators in all aspects of the antimicrobial pathway. Patient advocacy appears to be a strong driver of bedside nurses' activities.

Conclusions

Nurses' activities are already integrated in the day-to-day nursing practice and are grounded in the essence of nursing, being a patient advocate and showing nursing leadership in safeguarding the antimicrobial treatment process. An essential element of the nursing role is communication with other stakeholders in the patient-centred antimicrobial pathway. Educating, engaging and empowering nurses in this already integrated role, could lead to a solid, impactful nursing contribution to AMS.

Biomarkers for febrile urinary tract infection in children

Background

The current reference standard for pediatric urinary tract infection (UTI) screening, the leukocyte esterase (LE) dipstick test, has suboptimal accuracy. The objective of this study was to compare the accuracy of novel urinary biomarkers to that of the LE test.

Methods

We prospectively enrolled febrile children who were evaluated for UTI based on their presenting symptoms. We compared the accuracy of urinary biomarkers to that of the test.

Results

We included 374 children (50 with UTI, 324 without UTI, ages 1-35 months) and examined 35 urinary biomarkers. The urinary biomarkers that best discriminated between febrile children with and without UTI were urinary neutrophil gelatinase-associated lipocalin (NGAL), IL-1β, CXCL1, and IL-8. Of all examined urinary biomarkers, the urinary NGAL had the highest accuracy with a sensitivity of 90% (CI: 82-98) and a specificity of 96% (CI: 93-98).

Conclusion

Because the sensitivity of the urinary NGAL test is slightly higher than that of the LE test, it can potentially reduce missed UTI cases. Limitations of using urinary NGAL over LE include increased cost and complexity. Further investigation is warranted to determine the cost-effectiveness of urinary NGAL as a screening test for UTI.

Urinary HSP70 improves diagnostic accuracy for urinary tract infection in children: UTILISE study

BACKGROUND

The accuracy of conventional urinalysis in diagnosing urinary tract infection (UTI) in children is limited, leading to unnecessary antibiotic exposure in a large fraction of patients. Urinary heat shock protein 70 (uHSP70) is a novel marker of acute urinary tract inflammation. We explored the added value of uHSP70 in discriminating UTI from other infections and conditions confused with UTI.

METHODS

A total of 802 children from 37 pediatric centers in seven countries participated in the study. Patients diagnosed with UTI (n = 191), non-UTI infections (n = 178), contaminated urine samples (n = 50), asymptomatic bacteriuria (n = 26), and healthy controls (n = 75) were enrolled. Urine and serum levels of HSP70 were measured at presentation in all patients and after resolution of the infection in patients with confirmed UTI.

RESULTS

Urinary (u)HSP70 was selectively elevated in children with UTI as compared to all other conditions (p < 0.0001). uHSP70 predicted UTI with 89% sensitivity and 82% specificity (AUC = 0.934). Among the 265 patients with suspected UTI, the uHSP70 > 48 ng/mL criterion identified the 172 children with subsequently confirmed UTI with 90% sensitivity and 82% specificity (AUC = 0.862), exceeding the individual diagnostic accuracy of leukocyturia, nitrite, and leukocyte esterase positivity. uHSP70 had completely normalized by the end of antibiotic therapy in the UTI patients. Serum HSP70 was not predictive.

CONCLUSIONS

Urine HSP70 is a novel non-invasive marker of UTI that improves the diagnostic accuracy of conventional urinalysis. We estimate that rapid urine HSP70 screening could spare empiric antibiotic administration in up to 80% of children with suspected UTI. A higher resolution version of the Graphical abstract is available as Supplementary information.

The impact of Antimicrobial Stewardship Programmes in paediatric emergency departments and primary care: a systematic review

Background

Antibiotics remain the most prescribed medicine in children worldwide, but half of the prescriptions are unnecessary or inappropriate, leading to an increase in antibiotic resistance. This study aims to systemically review the effects of different Antimicrobial Stewardship Programmes (ASPs) on reducing the rates of both antibiotic prescriptions and changes in antimicrobial resistance, and on the economic impact in paediatric emergency departments (PED) and primary care settings.

Materials and methods

Embase, MEDLINE, and Cochrane Library were systematically searched, combining Medical Subject Heading and free-text terms for 'children' and 'antimicrobial' and 'stewardship'. The search strategy involved restrictions on dates (from 1 January 2007 to 30 December 2020) but not on language. Randomized controlled trials, controlled and non-controlled before and after studies, controlled and non-controlled interrupted time series, and cohort studies were included for review. The review protocol was registered at the PROSPERO International Prospective Register of Systematic Reviews: Registration Number CRD42021270630.

Results

Of the 47,158 articles that remained after removing duplicates, 59 were eligible for inclusion. Most of the studies were published after 2015 (37/59, 62.7%) and in high-income countries (51/59, 86.4%). Almost half of the studies described the implementation of an ASP in the primary care setting (28/59, 47.5%), while 15 manuscripts described the implementation of ASPs in EDs (15/59, 25.4%). More than half of the studies (43/59, 72.9%) described the implementation of multiple interventions, whereas few studies considered the implementation of a single intervention. Antibiotic prescriptions and compliance with guidelines were the most frequent outcomes (47/59, 79.7% and 20/59, 33.9%, respectively). Most of the articles reported an improvement in these outcomes after implementing an ASP. Meanwhile, only very few studies focused on health care costs (6/59, 10.2%) and antimicrobial resistance (3/59 5.1%).

Conclusion

The implementation of ASPs has been proven to be feasible and valuable, even in challenging settings such as Emergency Departments and Primary care.

Decreasing Misdiagnoses of Urinary Tract Infections in a Pediatric Emergency Department

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.

Predictors of Empiric Antibiotic Use in the Emergency Department in Children Without Urinary Tract Infections

OBJECTIVES

Urinary tract infections (UTIs) are a common diagnosis within the pediatric emergency department (ED). Because of the necessary delay in obtaining urine culture results, clinicians must decide whether to prescribe antibiotics for a suspected UTI before urine culture results. The primary objective of this study was to identify the proportion of children given empiric antibiotics who subsequently did not meet consensus definition of an UTI. The secondary objective was to identify factors associated with return visits to the ED after an index visit for UTI. We also attempted to identify predictors of prescription of empiric antibiotics for children who did not have a UTI.

METHODS

This was a retrospective chart review of all patients between the ages of 2 months and 18 years diagnosed with a UTI between July 2016 and June 2017 in the ED of a single urban quaternary care center. Patients were excluded for the following reasons: use of bag for urine collection, subsequent admission to the hospital, receipt of antibiotics within the previous 3 days, use of antibiotics for an indication other than a UTI, and urine culture obtained at an outside facility.

RESULTS

Of 404 included patients, 389 (96.2%) were discharged on antibiotics and 243 (62.4%) did not have a UTI. On the multivariate analysis, age ≧ 36 months was associated with increased odds of receiving antibiotics and not having a UTI while both ≥1+ leukocyte esterase and ≥1+ nitrites on urinalysis were associated with decreased odds of receiving antibiotics and not meeting UTI criteria. Sixty-two patients revisited the ED within 30 days of the initial visit, 24 (38.7%) of which met criteria for UTI during the index visit. Prescription of antibiotics at the time of the index visit was associated with decreased odds of reutilization, whereas an extended-spectrum β-lactamase producing organism cultured from urine at the index visit was associated with increased odds of reutilization.

CONCLUSIONS

A high number of patients discharged on empiric antibiotics did not meet criteria for a UTI. We did not identify clinically useful factors that predicted prescription of empiric antibiotics for children who do not have a UTI. We believe that unnecessary antibiotic prescriptions could be substantially decreased by decreasing empiric use of antibiotics coupled with reliable follow-up for positive urine cultures.

Accuracy of Antibiotic Prescription Dosing for Urinary Tract Infections in a Regional Pediatric Ambulatory Care Setting

OBJECTIVE

Antibiotics are the most common class of medication prescribed in pediatrics, with the majority of prescriptions occurring in the outpatient setting. Our objective was to evaluate the accuracy of antibiotic dose, frequency, and formulation prescribed for urinary tract infections (UTIs) in the pediatric ambulatory care setting.

METHODS

This was a retrospective review of electronic medical records conducted at 2 suburban pediatric practices in a mid-sized metropolitan region. Encounter-related prescriptions were identified using UTI-associated International Classification of Diseases, 10th Revision codes. Patients aged 2 months through 18 years were included if they had been prescribed an oral antibiotic for the treatment of UTI. Antibiotic dose, frequency, and formulation were considered accurate if consistent with clinical guidelines and tertiary dosing references.

RESULTS

Nearly 1 in 4 prescriptions had dosing inaccuracies. The proportion of errors was highest with amoxicillin-clavulanate (75%; 9/12) and amoxicillin (52%; 33/64). The most common reasons for dosing incorrectly were "low dose" or "unnecessarily high dose." Additionally, 55% of the included prescriptions were for oral suspensions, and 1 in 4 of these were dosed incorrectly.

CONCLUSIONS

Inaccuracies in antibiotic prescribing for pediatric UTI are common, including for frequently prescribed agents and oral formulations. To address these missed opportunities for stewardship in the outpatient setting, key educational sessions with providers should include reviewing optimal antibiotic dosing for uropathogens and highlighting common errors when oral suspensions are prescribed.

Biomarkers for febrile urinary tract infection in children

BACKGROUND

The sensitivity and specificity of the leukocyte esterase test for the diagnosis of urinary tract infection (UTI) are suboptimal. Recent studies have identified markers that appear to more accurately differentiate children with and without UTI. The objective of this study was to determine the accuracy of these markers, which included CCL3, IL-8, CXCL1, TNF-alpha, IL-6, IFN-gamma, IL-17, IL-9, IL-2, and NGAL, in the diagnosis of UTI.

METHODS

This was a prospective cross-sectional study to compare inflammatory proteins between urine samples from febrile children with a UTI, matched febrile controls without a UTI, and asymptomatic healthy controls.

RESULTS

We included 192 children (75 with febrile UTI, 69 febrile controls, and 48 asymptomatic healthy controls). Urinary proteins that best discriminated between febrile children with and without UTI were NGAL, a protein that exerts a local bacteriostatic role in the urinary tract through iron chelation; CCL3, a chemokine involved in leukocyte recruitment; and IL-8, a cytokine involved in neutrophil recruitment. Levels of these proteins were generally undetectable in asymptomatic healthy children.

CONCLUSIONS

NGAL, CCL3, and IL-8 may be useful in the early diagnosis of UTI.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT01391793) A higher resolution version of the Graphical abstract is available as Supplementary information.

Evaluating the Addition of a Clinical Pharmacist Service to a Midlevel Provider-Driven Culture Follow-up Program in a Community Emergency Department

Background: The impact that an antimicrobial stewardship program can have on an inpatient setting has been well documented, but there are limited data on the use of an antimicrobial stewardship program in the emergency department (ED). Objective: The objective of this study was to assess the impact of adding a pharmacist service to a midlevel provider-driven culture follow-up program in the ED on achieving optimal therapy. Methods: This was a quasi-experimental study with designations of pre- and post-interventions conducted at a large community hospital with the pre-intervention phase occurring from June 1, 2019, to August 31, 2019, and the post-intervention phase occurring from January 1, 2020, to March 31, 2020. The primary outcome was optimal antimicrobial therapy: a composite of optimal antibiotic, dose, and duration, prescribed after the culture resulted. Secondary outcomes included optimal antibiotic, dose, duration, and return to the ED within 30 days due to infection. Results: Optimal antimicrobial therapy received after the culture resulted occurred in 59 patients (26.81%) in the pre-implementation phase and 40 patients (43.96%) in the implementation phase (P = .003). For the secondary outcomes, optimal antibiotic choice occurred in 115 patients (52.27%) in the pre-implementation phase and 66 patients (72.53%) in the implementation phase (P = .001). Optimal antibiotic dose occurred in 113 patients (51.36%) in the pre-implementation phase and 65 patients (71.43%) in the implementation phase (P = .001). Optimal antibiotic duration occurred in 65 patients (29.55%) in the pre-implementation phase and 40 patients (43.96%) in the implementation phase (P = .014). Conclusions: The addition of a clinical pharmacist service in a midlevel provider-driven ED culture callback program resulted in an increased rate of achieving optimal antimicrobial therapy.

Outpatient Urinary Tract Infections in an Era of Virtual Healthcare: Trends From 2008 to 2017

BACKGROUND

Urinary tract infections (UTIs) occur commonly, but recent data on UTI rates are scarce. It is unknown how the growth of virtual healthcare delivery affects outpatient UTI management and trends in the United States.

METHODS

From 1 January 2008 to 31 December 2017, UTIs from outpatient settings (office, emergency, and virtual visits) were identified from electronic health records at Kaiser Permanente Southern California using multiple UTI definitions. Annual rates estimated by Poisson regression were stratified by sex, care setting, age, and race/ethnicity. Annual trends were estimated by linear or piecewise Poisson regression.

RESULTS

UTIs occurred in 1 065 955 individuals. Rates per 1000 person-years were 53.7 (95% confidence interval [CI], 50.6-57.0) by diagnosis code with antibiotic and 25.8 (95% CI, 24.7-26.9) by positive culture. Compared to office and emergency visits, UTIs were increasingly diagnosed in virtual visits, where rates by diagnosis code with antibiotic increased annually by 21.2% (95% CI, 16.5%-26.2%) in females and 29.3% (95% CI, 23.7%-35.3%) in males. Only 32% of virtual care diagnoses had a culture order. Overall, UTI rates were highest and increased the most in older adults. Rates were also higher in Hispanic and white females and black and white males.

CONCLUSIONS

Outpatient UTI rates increased from 2008 to 2017, especially in virtual care and among older adults. Virtual care is important for expanding access to health services, but strategies are needed in all outpatient care settings to ensure accurate UTI diagnosis and reduce inappropriate antibiotic treatment.

Predicting Urinary Tract Infections With Interval Likelihood Ratios

BACKGROUND

Protocols for diagnosing urinary tract infection (UTI) often use arbitrary cutoff values of urinalysis components to guide management. Interval likelihood ratios (ILRs) of urinalysis results may improve the test's precision in predicting UTIs. We calculated the ILR of urinalysis components to estimate the posttest probabilities of UTIs in young children.

METHODS

Review of 2144 visits to the pediatric emergency department of an urban academic hospital from December 2011 to December 2019. Inclusion criteria were age <2 years and having a urinalysis and urine culture sent. ILR boundaries for hemoglobin, protein, and leukocyte esterase were "negative," "trace," "1+," "2+" and "3+." Nitrite was positive or negative. Red blood cells and white blood cells (WBCs) were 0 to 5, 5 to 10, 10 to 20, 20 to 50, 50 to 100, and 100 to 250. Bacteria counts ranged from negative to "loaded." ILRs for each component were calculated and posttest probabilities for UTI were estimated.

RESULTS

The UTI prevalence was 9.2%, with the most common pathogen being Escherichia coli (75.2%). The ILR for leukocyte esterase ranged from 0.20 (negative) to 37.68 (3+) and WBCs ranged from 0.24 (0-5 WBCs) to 47.50 (100-250 WBCs). The ILRs for nitrites were 0.76 (negative) and 25.35 (positive). The ILR for negative bacteria on urinalysis was 0.26 and 14.04 for many bacteria.

CONCLUSIONS

The probability of UTI in young children significantly increases with 3+ leukocyte esterase, positive nitrite results, 20 to 50 or higher WBCs, and/or many or greater bacteria on urinalysis. The probability of UTI only marginally increases with trace or 1+ leukocyte esterase or 5 to 20 WBCs. Our findings can be used to more accurately predict the probability of true UTI in children.

Under-utilization of Narrow-Spectrum Antibiotics in the Ambulatory Management of Pediatric UTI: A Single-Center Experience

Objective: There are urinary tract infection (UTI) guidelines for treatment of patients <2 years old, but there is a paucity of data for other pediatric age groups including the potential role for stewardship to reduce prescription of broad-spectrum antibiotics. We assessed practice patterns for the diagnosis and empiric treatment of UTI for outpatient and school health sites affiliated with a large urban pediatric medical center. We hypothesized that outpatient providers under-utilize narrow-spectrum antibiotics, such as first-generation cephalosporins, for uncomplicated UTI. Study Design: Retrospective study from December 1st, 2015 to May 31st, 2016. Results: The study population included 903 children (70.1% female) with a median age of 11 years, evaluated in an outpatient clinic (n = 780, 86.4%) or school health site (n = 123, 13.6%). E. coli was the most common urinary pathogen (50.9%) and 92.6% of E. coli isolates were susceptible to cephalexin. However, cephalexin was prescribed empirically for only 12.8% of patients. In contrast, sulfamethoxazole-trimethoprim was commonly prescribed, but only 79% of E. coli isolates were susceptible. Antibiotics were discontinued in only three of 48 children who had negative urine cultures. Conclusions: Cephalexin may be the most appropriate first-line choice for management of outpatient UTI for our patient population. Antibiotics were rarely discontinued for those with negative urine cultures. Antibiotic stewardship in the outpatient setting could reduce unnecessary antibiotic exposure in the management of pediatric UTI.

Decreasing review and notification times of genital and urine cultures in a pediatric emergency department: An observational before and after study

OBJECTIVES

The review of positive culture results by clinical pharmacists in pediatric patients discharged from the emergency department (ED) has not been described. This study aimed to compare review and family notification times of genital and urine cultures before and after initiation of review of positive cultures by clinical pharmacists in a pediatric ED.

METHODS

This was a retrospective review of charts for the study period of 1 year before and 1 year after initiation of review of positive cultures by clinical pharmacists. Positive culture timing results as well as types and rates of interventions were obtained from the electronic chart records.

RESULTS

A total of 681 urine and 171 genital cultures were analyzed. The number of genital and urine cultures were similar in the nurse-driven and pharmacist-driven periods. For urine cultures, the cumulative percentage of notifications in the pharmacist-driven period exceeded that in the nurse-driven period until about 24 hours and again between 24 and 48 hours. By 12 hours, 5.4% of families had been notified in the pharmacist-driven period compared with 1.8% in the nurse-driven period (P = 0.011). More positive cultures were reviewed early in the pharmacist-driven period as well, but by 12 hours, the cumulative percentages were similar: 30.4% in the pharmacist-driven period compared with 27.7% in the nurse-driven period (P = 0.431). For genital cultures, the distribution of notification and review times were similar in both periods.

CONCLUSIONS

The review of positive cultures by clinical pharmacists in a pediatric ED can shorten review and notification times compared with nurses, especially in the first 12 hours.

Urine neutrophil gelatinase-associated lipocalin in girls with recurrent urinary tract infections

BACKGROUND

Children who experience more than one urinary tract infection (UTI) are at increased risk of kidney scarring due to their UTIs. Girls are at especially high risk for developing kidney scarring as a result of recurrent UTIs. Prior work suggested that neutrophil gelatinase-associated lipocalin (NGAL) may be lower in children with recurrent UTI compared with those without. The objective of this work was to compare urine NGAL concentrations in matched urine samples in girls with single and recurrent UTIs.

METHODS

Girls less than 6 years of age who presented with signs and symptoms of a UTI were eligible for enrollment. Both acute, obtained from residual urine collected as part of their clinical evaluation, and follow-up urine samples, obtained after the completion of antibiotics when the patient was in their usual state of health, were collected from patients. Acute and follow-up urine NGAL concentrations were compared between girls with single and recurrent UTIs, as well as those with negative cultures who served as controls.

RESULTS

Seventy girls were included in this study, 6 controls, 43 single UTIs, and 20 girls with recurrent UTIs. Patients in the control group had lower median acute NGAL concentrations than either those with single or recurrent UTI. There were no differences in either acute or follow-up urine NGAL concentrations between those with single and recurrent UTIs.

CONCLUSION

In this cohort of girls less than 6 years of age, there is no difference in urine NGAL concentrations between those with single and recurrent UTIs.

Nurse role and contribution to antimicrobial stewardship: An integrative review

AIM

To examine existing published literature regarding nurses and antimicrobial stewardship, and their potential role and contribution, to identify what is known, to evaluate methodologies used in published research, and to review and integrate findings to inform practice and future priorities for research.

DESIGN

Integrative review.

METHODOLOGY

The approach to this review was informed by Whittemore and Knafl's integrative review methodology. Electronic databases were searched for papers published since the start of the database to November 2019, with abstracts available, related to humans and published in English. Papers were included regardless of practice setting (acute, aged, and primary care) and if they were research based, included nurses as participants and reported specifically on results from nurses or that had implications for nursing practice. Excluded were conference abstracts, and papers focussed solely on nurse prescriber, nurse practitioner, or nurse manager roles.

RESULTS

Fifty-two papers were included in the review. Identified themes were: i) nursing knowledge, learning needs and education; ii) nurse perceptions of the nursing role and motivations for involvement; iii) nursing brokerage and influence on information flow to and from patients; iv) nursing workflow, workload and workarounds; and v) nurse leadership. Methodological quality of the included papers varied, limiting transferability and applicability of findings for some of the included studies.

CONCLUSION

Formal inclusion of nurses in antimicrobial stewardship activities has been associated with improved nurse knowledge, nurse confidence, and in some cases improved clinical outcomes for patients. The review reinforces nursing values as a motivator of nursing actions, and reveals the complex yet significant influence of nurses on antimicrobial prescribing. Potential opportunities to enhance nurses' participation and contribution to antimicrobial stewardship include; formal acknowledgement of the nurse role, educating nurses so that they are aware of how they can contribute, collaborating with nurses in planning and implementing local stewardship activities, and ensuring nurse leaders are involved. However, evidence on this topic remains limited. Research is needed to facilitate greater understanding about the nature, scope and influence of the nurse role in antimicrobial stewardship, how nurses enact and carry out their role, and nurses' support needs. Tweetable abstract: Integrative review explores #nurse role in #antimicrobialstewardship. Nurse contribution, influence significant, but not well understood.

Antibiotic prescribing patterns for adult urinary tract infections within emergency department and urgent care settings

Urinary tract infections (UTI) are a common reason for emergency department (ED) and urgent care (UC) visits. Fluoroquinolones (FQ) are frequently prescribed for treatment of UTI in the outpatient setting; however, data evaluating prescribing patterns after FDA safety warnings is limited, especially in UC. The study goal was to investigate and compare antimicrobial prescribing for UTIs in a single-site ED and an off-site UC in an urban, academic health system. This retrospective study included patients presenting with a UTI to the ED or UC between January and June 2018. Those 18 years or older with uncomplicated, complicated UTI, or pyelonephritis were included. Exclusion criteria were catheter-related UTI, urinary tract abnormalities, immunocompromised, or hospitalization. Primary outcome was FQ prescribing rate for all UTI in the ED and UC. Secondary outcomes were rates of non-FQ prescribing, re-presentation, bug-drug mismatch, and treatment durations. 184 patients were included. FQ prescribing rate was similar in ED and UC (21.2% vs. 16.3%, p = 0.4). Non-FQs prescribed in ED and UC were nitrofurantoin (20.2% vs 53.6%), beta-lactams (46.1% vs 22.6%), and trimethoprim/sulfamethoxazole (12.5% vs. 5%). A longer than recommended duration was identified in 46.3% UC patients compared to 21.2% ED patients. Thirty-day re-presentation with persistent UTI symptoms occurred more frequently in the ED compared to UC (13.5% vs. 7.5%). Predictors of FQ prescribing on logistic regression were male, recurrent UTI, and malignancy. FQ prescribing rate for UTI treatment was low with no difference between ED and UC. Opportunity exists to improve treatment duration and antimicrobial choice.

Antimicrobial stewardship in the outpatient setting: A review and proposed framework

Antimicrobial misuse is still a significant problem, and most inappropriate use occurs in the outpatient setting. In this article, we provide a review of available literature on outpatient antimicrobial stewardship in primary care settings, and we propose a novel implementation framework.

Optimal Antibiotics at Hospital Discharge for Children With Urinary Tract Infection

OBJECTIVES

Antibiotic stewardship at hospital discharge is an area of need. We assessed the rate of optimal antibiotic prescriptions at hospital discharge, on the basis of urine culture and susceptibility data, for children diagnosed with a urinary tract infection (UTI).

METHODS

We conducted a retrospective study of patients ≤18 years of age who were admitted to a general pediatrics service at a freestanding children's hospital during 2017 with a diagnosis of UTI and received an antibiotic prescription at discharge. For the primary analysis, optimal antibiotic at hospital discharge was determined by evaluating if the cultured urinary pathogen was susceptible to the prescribed antibiotic and if the antibiotic was the narrowest-spectrum option available. Secondary objectives included assessment of antibiotic dosing accuracy and description of antibiotic treatment duration.

RESULTS

A total of 78 cases were included. Sixty-eight (83%) cases were caused by cefazolin-susceptible Escherichia coli and Klebsiella species. Thirty-one (40%) cases had a discharge antibiotic prescription that was determined to be optimal. Of the 47 (60%) cases that were suboptimal, 44 (94%) were considered to be excessively broad spectrum. In 3 (6%) cases, the causative organism was nonsusceptible to the prescribed antibiotic. Ten (13%) discharge antibiotic prescriptions had inaccurate dosing and/or frequency.

CONCLUSIONS

Missed opportunities for narrow-spectrum antibiotic selection at hospital discharge for pediatric UTIs frequently occurred. In particular, higher-generation cephalosporins and ciprofloxacin were often prescribed for cephalexin-susceptible cases. Antibiotic stewardship attention, specifically at hospital discharge for pediatric UTIs, is likely to have a high impact.

Appropriateness of Antibiotic Prescriptions for Urinary Tract Infections

Introduction

Urinary tract infections (UTI) are a common indication for antibiotic use in the emergency department (ED). With antibiotic resistance on the rise, it is essential that antibiotics be prescribed appropriately for UTIs. Our objective was to evaluate the appropriateness of antibiotic prescriptions by ED providers for uncomplicated cystitis and pyelonephritis.

Methods

We conducted a retrospective study of females ages 2–50 years seen in an academic ED from January 2017 to April 2018 diagnosed with UTI. We assessed the appropriateness of discharge antibiotic prescriptions, as determined by adherence to clinical practice guidelines, best evidence for the particular indication (cystitis vs pyelonephritis for children and adults), and the local antibiogram.

Results

A total of 421 patients were included in this study. Of these, 60 children and 198 adults were diagnosed with cystitis, and 47 children and 116 adults were diagnosed with pyelonephritis. Treatment in the absence of true infection was common, with culture-confirmed UTI occurring in only 17/50 (34%) of children and 60/129 (47%) of adults diagnosed with cystitis, and 23/40 (58%) of children and 58/87 (67%) of adults diagnosed with pyelonephritis, among patients who had urine cultures. The type of antibiotic prescribed was appropriate in 53/60 (88%) of children and 135/198 (68%) of adults with cystitis, and 38/47 (81%) of children and 53/116 (46%) of adults with pyelonephritis. The most common inappropriate antibiotic types were beta-lactams in adults (n = 92), nitrofurantoin for pyelonephritis (n = 16), and amoxicillin (n = 15). Dosing and duration errors were also common, occurring in 122/279 (44%) of prescriptions of an appropriate antibiotic type. The frequency of errors in the type of antibiotic prescribed was similar among provider types (attending physician, resident physician, and advanced practice clinician; p = 0.926).

Conclusion

This study reveals room for improvement in antibiotic prescription practices across provider cohorts in the ED for the management of uncomplicated cystitis and pyelonephritis in females.

Implementation and impact of pediatric antimicrobial stewardship programs: a systematic scoping review

Background

Antibiotics are the most common medicines prescribed to children in hospitals and the community, with a high proportion of potentially inappropriate use. Antibiotic misuse increases the risk of toxicity, raises healthcare costs, and selection of resistance. The primary aim of this systematic review is to summarize the current state of evidence of the implementation and outcomes of pediatric antimicrobial stewardship programs (ASPs) globally.

Methods

MEDLINE, Embase and Cochrane Library databases were systematically searched to identify studies reporting on ASP in children aged 0-18 years and conducted in outpatient or in-hospital settings. Three investigators independently reviewed identified articles for inclusion and extracted relevant data.

Results

Of the 41,916 studies screened, 113 were eligible for inclusion in this study. Most of the studies originated in the USA (52.2%), while a minority were conducted in Europe (24.7%) or Asia (17.7%). Seventy-four (65.5%) studies used a before-and-after design, and sixteen (14.1%) were randomized trials. The majority (81.4%) described in-hospital ASPs with half of interventions in mixed pediatric wards and ten (8.8%) in emergency departments. Only sixteen (14.1%) studies focused on the costs of ASPs. Almost all the studies (79.6%) showed a significant reduction in inappropriate prescriptions. Compliance after ASP implementation increased. Sixteen of the included studies quantified cost savings related to the intervention with most of the decreases due to lower rates of drug administration. Seven studies showed an increased susceptibility of the bacteria analysed with a decrease in extended spectrum beta-lactamase producers E. coli and K. pneumoniae; a reduction in the rate of P. aeruginosa carbapenem resistance subsequent to an observed reduction in the rate of antimicrobial days of therapy; and, in two studies set in outpatient setting, an increase in erythromycin-sensitive S. pyogenes following a reduction in the use of macrolides.

Conclusions

Pediatric ASPs have a significant impact on the reduction of targeted and empiric antibiotic use, healthcare costs, and antimicrobial resistance in both inpatient and outpatient settings. Pediatric ASPs are now widely implemented in the USA, but considerable further adaptation is required to facilitate their uptake in Europe, Asia, Latin America and Africa.

Collaborative Antimicrobial Stewardship in the Health Department

Given the population-level implications of antibiotic resistance and the importance of antibiotic stewardship in containment and prevention of resistance, public health has a vested interest in strengthening antibiotic stewardship efforts. There are opportunities for public health collaboration at all levels including local health departments, state public health programs, and through federal public health entities. This article discusses existing public health stewardship activities, opportunities for collaboration between public health and key partners in antibiotic stewardship programs, the potential for improvement and expansion of current activities, and possible new modes of collaboration that could be pursued.

Scope of Antibiotic Stewardship Programs in Pediatrics

This review of pediatric antibiotic stewardship programs (ASPs) summarized the antibiotic prescribing interventions and their impact on antibiotic use and antimicrobial resistance. We reviewed studies of pediatric ASP, including the search terms "antimicrobial stewardship," "antibiotic stewardship," "children," and "pediatric." The articles' selection and review were performed independently by 2 investigators, according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Twenty-one studies were included, from the past 15 years, increasing after the 2007 IDSA (Infectious Diseases Society of America) guidelines for ASP with a large variability of the programs, and the virtual exclusive focus on inpatient settings (90%): 16 formalized ASP and 5 non-ASP actions. A reduction in antibiotic prescribing in ASP has been demonstrated in the studies reporting pediatric ASP, but only one ASP showed a significant impact on antimicrobial resistance. However, the impact on antibiotic consumption in pediatrics demonstrated the important contribution of these strategies to improve antibiotic use in children, without complications or negative issues.

Evaluation of BacterioScan 216Dx in Comparison to Urinalysis as a Screening Tool for Diagnosis of Urinary Tract Infections in Children

Urinalysis (UA) has routinely been used as a screening tool prior to urine culture set up. BacterioScan 216Dx is an FDA-cleared semiautomated system to detect bacterial growth in urine. The aim of this study was to evaluate 216Dx in comparison to UA for diagnosis of urinary tract infection (UTI) in children. Clean-catch, unpreserved urine samples from children aged <18 years were tested by 216Dx, and positive urine samples in media were processed for direct bacterial identification by matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) mass spectrometry. Sensitivity and specificity of 216Dx and urinalysis (UA) were determined against urine culture. Of 287 urine samples obtained from children (median age, 108 months), 44.0% and 56.0% were UA positive and negative, respectively, while 216Dx detected 27% and 73% as positive and negative, respectively. Compared to culture, the overall sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 216Dx versus UA were 92.1% versus 97.3%, 82.7% versus 63.8%, 44.8% versus 29.1%, and 98.6% versus 99.3%, respectively. Among 216Dx true-positive (TP) samples (n = 35), 77.0% were successfully identified directly from broth by MALDI-TOF. Among urine samples that were identified as contaminated by culture (n = 127; 44%), the 216Dx detected 93 (73.0%) as negative while UA detected 69 (54.0%) as negative. Although the sensitivities of 216Dx and UA are comparable, the specificity of 216Dx was higher than that of UA. The 216Dx can be used as an alternative/adjunct screening tool to UA to rule out urinary tract infection (UTI) in children. Compared to culture, the faster turnaround time (3 hours) of 216Dx has the potential to reduce unnecessary antibiotic use and improve patient management.

Pharmacist-led antimicrobial stewardship program in an urgent care setting

Purpose

While many programs have demonstrated pharmacist-led antimicrobial stewardship successes in inpatient and emergency department (ED) settings, there is a paucity of literature exploring these initiatives in urgent care (UC) sites. This study aimed to determine the impact of implementing a pharmacist-led antimicrobial stewardship program (ASP) in the UC setting.

Methods

A retrospective quasi-experimental study was conducted evaluating UC patients with positive urine or wound cultures following discharge. A collaborative practice agreement was implemented in 2015 allowing for pharmacist-led UC culture follow-up via a stewardship-focused protocol. The primary outcome of this study was to compare guideline-concordant antibiotic prescribing between the pre-ASP and post-ASP groups. Secondary outcomes included comparing the number of patients who required follow-up, time to follow-up, UC or ED revisits within 72 hours, and hospital admission within 30 days between groups.

Results

A total of 300 patients were included in the study (pre-ASP, n = 150; post-ASP, n = 150). Total guideline-concordant prescribing for all diagnoses was significantly improved in the post-ASP group (pre-ASP, 41.3% versus post-ASP 53.3%, p = 0.037). Additionally, guideline-concordant antibiotic selection improved in the post-ASP group (pre-ASP, 51% versus post-ASP, 68%, p = 0.01). Follow-up was required for 27 (18%) patients in the pre-ASP group compared with 16 (10.7%) in the post-ASP group (p = 0.07). Median time to follow-up call was longer in the post-ASP group (38 versus 71 hours, p < 0.001). There were no differences in UC and ED revisits within 72 hours (p = 1.0) or hospital admissions within 30 days (p = 0.723).

Conclusion

A pharmacist-led urgent care ASP was associated with significantly improved guideline-concordant antimicrobial prescribing.

Outpatient Pediatric Antibiotic Use: a Systematic Review

PURPOSE OF REVIEW

The majority of pediatric antibiotic use occurs in outpatients. However, the optimal strategies for antimicrobial stewardship in this setting are unknown. We sought to identify studies relevant to pediatric outpatient stewardship that have been published in the past decade. The details of this systemic review are presented along with targets for future stewardship efforts and discussion regarding effective outpatient stewardship strategies.

RECENT FINDINGS

In 2016, the CDC released the "Core Elements of Outpatient Antibiotic Stewardship" that serve as practical guidelines to develop impactful and sustainable ASP interventions: commitment, action for policy and practice, tracking and reporting, and education and expertise. However, there has not been a recent review of the primary medical literature on pediatric outpatient stewardship. A systematic review of pediatric antibiotic control strategies published in 2007 identified 28 studies overall, 8 of which focused on outpatients. Two subsequent systematic reviews published in 2015 and 2018 intentionally excluded outpatients. Outpatient settings are a crucial component of pediatric antimicrobial stewardship in the USA. Establishing effective stewardship interventions can protect children and optimize clinical outcomes in outpatient healthcare settings. Based on our review of the literature, it is clear that the optimal outpatient stewardship strategies remain to be elucidated. However, there is robust literature describing variability in outpatient antibiotic prescribing that can be used to target interventions.

Outpatient antimicrobial stewardship targets for treatment of skin and soft-tissue infections

OBJECTIVE

We sought to identify factors associated with long duration and/or non-first-line choice of treatment for pediatric skin and soft-tissue infections (SSTIs).

DESIGN

Retrospective cohort study.

SETTING

Ambulatory encounter claims of Medicaid-insured children lacking chronic medical conditions treated for SSTI and/or animal bite injury in Ohio in 2014.

METHODS

For all diagnoses, long treatment duration was defined as treatment >7 days. Non-first-line choice of treatment for SSTI included treatment with 2 antimicrobials dispensed on the same calendar day or any treatment not listed in the Infectious Diseases Society of America guidelines. The adjusted odds of (1) long treatment duration and (2) non-first-line choice of treatment were calculated for patient age, prescriber type, and patient county of residence characteristics (ie, rural vs metropolitan area and poverty rate).

RESULTS

Of 10,310 encounters with complete data available, long treatment duration was prescribed in 7,968 (77.3%). The most common duration of treatment prescribed was 10 days. A non-first-line choice was prescribed in 1,030 encounters (10%). Dispensation of 2 antimicrobials on the same calendar day was the most common reason for the non-first-line choice, and of these, trimethoprim-sulfamethoxazole plus a first-generation cephalosporin was the most common regimen. Compared to pediatricians, the adjusted odds ratio of long treatment duration was significantly lower for all other primary care specialties. Conversely, nonpediatricians were more likely to prescribe a non-first-line treatment choice. Patient residence in a high-poverty county increased the odds of both long duration and non-first-line choice of treatment.

CONCLUSIONS

Healthcare claims may be utilized to measure opportunities for first-line choice and/or shorter duration of treatment for SSTI.

Outpatient Antibiotic Use and the Need for Increased Antibiotic Stewardship Efforts

Antibiotic-resistant infections pose a growing threat to public health. Antibiotic use, regardless of whether it is warranted, is a primary factor in the development of resistance. In the United States, the majority of antibiotic health care expenditures are due to prescribing in outpatient settings. Much of this prescribing is inappropriate, with research showing that at least 30% of antibiotic use in outpatient settings is unnecessary. In this State of the Art Review article, we provide an overview of the latest research on outpatient antibiotic prescribing practices in the United States. Although many of the researchers in these studies describe antibiotic prescribing across all patient age groups, we highlight prescribing in pediatric populations when data are available. We then describe the various factors that can influence a physician's prescribing decisions and drive inappropriate antibiotic use and the potential role of behavioral science in enhancing stewardship interventions to address these drivers. Finally, we highlight the role that a wide range of health care stakeholders can play in aiding the expansion of outpatient stewardship efforts that are needed to fully address the threat of antibiotic resistance.

Expanding Antimicrobial Stewardship to Urgent Care Centers Through a Pharmacist-Led Culture Follow-up Program

Introduction

Urgent care centers represent a high-volume outpatient setting where antibiotics are prescribed frequently but resources for antimicrobial stewardship may be scarce. In 2015, our pharmacist-led Emergency Department (ED) culture follow-up program was expanded to include two urgent care (UC) sites within the same health system. The UC program is conducted by ED and infectious diseases clinical pharmacists as well as PGY1 pharmacy residents using a collaborative practice agreement (CPA). The purpose of this study was to describe the pharmacist-led UC culture follow-up program and its impact on pharmacist workload.

Methods

This retrospective, descriptive study included all patients discharged to home from UC with a positive culture from any site resulting between 1 January and 31 December 2016. Data collected included the culture type, presence of intervention, and proportion of interventions made under the CPA. Additionally, pharmacist workload was reported as the number of call attempts made, new prescriptions written, and median time to complete follow-up per patient. Data were reported using descriptive statistics.

Results

A total of 1461 positive cultures were reviewed for antibiotic appropriateness as part of the UC culture follow-up program, with 320 (22%) requiring follow-up intervention. Culture types most commonly requiring intervention were urine cultures (25%) and sexually transmitted diseases (25%). A median of 15 min was spent per intervention, with a median of one call (range 1–6 calls) needed to reach each patient. Less than half of patients required a new antimicrobial prescription at follow-up.

Conclusion

A pharmacist-led culture follow-up program conducted using a CPA was able to be expanded to UC sites within the same health system using existing clinical pharmacy staff along with PGY1 pharmacy residents. Service expansion resulted in minimal increase in pharmacist workload. Adding UC culture follow-up services to an existing ED program can allow health systems to expand antimicrobial stewardship initiatives to satellite locations.