1353. Pediatric Urinary Tract Infections: A Choosing Wisely Initiative to Advance Antimicrobial Stewardship and Diagnostic Accuracy in the Emergency Department
Notice bibliographique
Résumé
Abstract Background Urinary tract infection (UTI) is a common diagnosis in the pediatric emergency department (ED) that often results in empiric antibiotic treatment prior to culture results. A 2016 cohort study from our centre found that 47% of children diagnosed with a UTI and prescribed antibiotics had a negative urine culture. None of these patients were notified of the misdiagnosis or told to discontinue antibiotics. Figure 1: Choosing Wisely pediatric urinary tract infection diagnostic algorithm Figure 2: Patients included/excluded with exclusion criteria Methods Institutional approval was obtained for a quality improvement project in our quaternary pediatric ED. For uncomplicated pediatric UTIs, the aim was to reduce misdiagnosis by 50% and promote antimicrobial stewardship over a 24-month period. Using the Model for Improvement, two interventions were implemented using PDSA cycles: (1) a UTI diagnostic algorithm embedded in the electronic medical record, (2) a urine culture callback system. Outcome measures included the percentage of patients with UTI misdiagnosis (urine culture negative) and antibiotic-days saved. Process measures included adherence to the UTI algorithm and callback system as well as antibiotic duration standardization. As a balancing measure, patients developing positive urine cultures without UTI diagnosis were reviewed for potential harm. Figure 3: Run chart of urinary tract infection misdiagnosis rate Figure 4: Callback system - Percent patients contacted and antibiotics-days saved Results From June 2017-April 2020, 2,183 children (0.97% of all visits) were diagnosed with a UTI in the ED. 1,381 (63.3%) met inclusion criteria for analysis. Following UTI algorithm launch, median UTI misdiagnosis decreased by 20% (52.5% vs. 32.5%), median correct antibiotic duration increased by 30% (45.2% vs. 75.1%), and algorithm adherence was 78.9%. With implementation of the callback system, 1,678 antibiotic-days were saved as mean patients contacted to discontinue antibiotics increased from 0% to 76.8%. Of 106 patients with positive urine cultures with missed UTI diagnosis over a 29-month period, 8 patients returned to the ED within 72 hours and 2 patients required admission for intravenous antibiotics. Conclusion Implementation of a UTI diagnostic algorithm and urine culture callback system for uncomplicated pediatric UTIs reduced UTI misdiagnosis and promoted antimicrobial and resource stewardship in the ED. Future directions include improving UTI algorithm adherence through targeted clinician audit and feedback, plus sustainability planning. Disclosures Olivia Ostrow, MD, Choosing Wisely Canada (Advisor or Review Panel member)
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Comment cette classification a été obtenuedéplier
Prédiction distillée sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Apprise à partir de 10 348 étiquettes directes de Codex et de 10 348 étiquettes directes de Gemma. Le mode candidate est l'union des têtes enseignantes seuillées; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont ni des étiquettes humaines ni des étiquettes directes de modèles de pointe.
Scores Codex et Gemma par catégorie
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,000 | 0,003 |
| Méta-épidémiologie (sens strict) | 0,000 | 0,000 |
| Méta-épidémiologie (sens large) | 0,000 | 0,000 |
| Bibliométrie | 0,000 | 0,001 |
| Études des sciences et des technologies | 0,000 | 0,000 |
| Communication savante | 0,000 | 0,001 |
| Science ouverte | 0,000 | 0,000 |
| Intégrité de la recherche | 0,000 | 0,000 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,000 | 0,000 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule tête enseignante, pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».