An Updated Approach to Urinary Tract Infections in Premature and Term Neonates: A Quality Improvement Project in a Level III Neonatal ICU

Corresponding Author Michael J Bozzella, DO, MS, Department of Pediatrics, Division of Infectious Diseases, University of Colorado, 13123 East 16th Avenue, Box 055, Aurora, CO 80045, USA, 617-817-5008, Michael.bozzella@childrenscolorado.org Funding This work was not supported by grant funding. Conflict(s) of Interest Michael J Bozzella, No conflict; Heather Johnson, No conflict; Allen Wu, No conflict; Mary Laird, No conflict. Background Urinary Tract Infections (UTI) can affect 0.1-1% or more of all infants in the neonatal intensive care unit (NICU). Despite being common, there is wide practice variation in diagnosis and treatment. At our facility, a multidisciplinary team completed a quality improvement project centered on UTI diagnosis and management in our NICU. We adapted and adopted a diagnostic and treatment pathway with a goal of standardizing practice and decreasing test-of-cure (TOC) utilization (obtaining repeat urine culture (UCx) at the end of UTI therapy looking for sterilization). We met with our NICU clinicians, obtained by-in, and incorporated the pathway into stewardship activities. Following our interventions, we achieved lasting practice change. Methods Patient records of infants admitted to the NICU with urine cultures obtained were reviewed over specified time periods focusing on the following: urinalysis (UA) and results, UCx and results, blood culture (BCx), empiric antibiotic use, and UTI treatment history. Baseline period: July 2021 – August 2023 (including time before and after implementation of antimicrobial stewardship program (ASP) in July 2022). A NICU specific diagnostic algorithm was implemented in September 2023. Post intervention period: September 2023-September 2024. Additional interventions included a follow-up session with NICU physicians in April of 2024 to report on progress and remind of the pathway, as well as reference to the pathway during Handshake rounds. Results 344 UCxs from 166 infants were reviewed. 48 UTIs were treated. Pre-intervention, the median rate of UCx with concurrent UA was ~46%, median rate of test-of-cure was ~14%, and median pathway adherence was ~48%. Post-intervention these medians changed to ~80% [Fig. 1], ~1% [Fig. 2], and 81% [Fig. 3] respectively. There were no occurrences of missed UTI (positive UCx or treated UTI within 7 days of prior evaluation). Conclusion In our NICU, adoption of a clinical pathway led to increased utilization of UCx with concurrent UA, decreased TOC, and more targeted treatment of UTI. Importantly this did not result in cases of “missed” UTI. This suggests that more stringent diagnostic criteria can be safely applied to this population, in turn leading to decreased antibiotic exposure and the associated potential long-term impacts associated with that exposure.