Guideline adherence of antibiotic prescriptions for urinary tract infections in a pediatric emergency department: a retrospective cohort study

Antimicrobial resistance (AMR) is a significant challenge. Adherence to data-driven local guidelines ensures effective treatment and limits AMR. Urinary tract infections (UTIs) in children are common and choices of empirical treatments represent an interesting opportunity for antimicrobial stewardship. To assess the appropriateness of antibiotic prescriptions for UTIs in a pediatric emergency department (ED) by identifying deviations from local hospital guidelines. This was a single center retrospective cohort study. Charts of eligible children treated in the ED of a tertiary care pediatric hospital in Montreal, Canada, between January and December 2022 were randomly sampled for evaluation. All children 18 years of age and less, with a presumptive diagnosis of UTI, who had a urine sample collected for urinalysis and culture were eligible. Patients who presented with concurrent infections were excluded. The primary outcome was the appropriateness of empiric prescriptions, based on compliance with hospital guidelines for antibiotic choice and dose. Independent variables included age, sex, past medical history (urinary tract abnormalities, prior UTIs, vesicoureteral reflux), allergies, temperature, urine sampling methods, urinalysis results and identified bacteria. The primary analysis was the proportion of appropriate antibiotic prescription. A total of 1029 children had a clinical diagnosis of UTI in the ED during the study period. We randomly sampled 449 participants, of which, 358 (79.8%) were eligible. The median age was 34 months, 253 (70.7%) were females and 96 (26.8%) were diagnosed with cystitis. Overall, 75 (20.9%; 95%CI: 16.9–25.5%) prescriptions were deemed inappropriate, more so in cases of cystitis (61.5%; 95%CI: 51.0-71.2%) than pyelonephritis (6.1%; 95%CI: 3.5–9.7%). The main reason for inappropriateness was the chosen antibiotic in 61 (83%) patients. In this pediatric population, antibiotic prescriptions for UTIs were commonly inappropriate for cystitis. These findings highlight an opportunity for improved antibiotic stewardship.