In a recently released issue of Pediatrics, an excellent quality improvement (QI) study by Dr. Dipsnwita Saha (10.1542/peds.2016-2103) and colleagues describes initiation of a process to discontinue antibiotics when a urine culture is negative for patients receiving care in their Pediatric Urgent Care Network. Typically one thinks of a quality improvement project as adding an intervention or intervention bundle, so that all eligible patients receive a treatment; in this interesting study eligible patients benefitted from not receiving a treatment, i.e. unnecessary antibiotics for a negative urine culture. The authors’ focus on follow up, rather than on decreasing initial prescribing, is supported by data documenting that about 50% of urinary tract infections are missed in primary care settings.1,2 Treating fewer children at initial presentation would thus be a QI strategy that awaits improved methods of urinary tract infection (UTI) identification.
The study included use of PDSA (plan,do,study,act) cycles and a standardized protocol with 5 steps from initial review of urine culture results by a nurse through clinician notification, assessment and decision making, to nurse notification to the patient, and then clinician documentation of the antibiotic discontinuation in the electronic medical record (EMR). Interestingly the most challenging step was the last, of clinician documentation, i.e. medication reconciliation, in the EMR. Since most inpatient and ambulatory EMRs are shared documents with multiple clinicians able to access and revise, in our own anecdotal experience this may lead to a lack of ownership by individual clinicians or to frustration with attempts to “clean up” the medical record. Whether this or simply time and knowledge were the barriers to clinician EMR documentation is not known, but the authors used email reminders with screen shots and in-person meetings to reinforce the medication reconciliation needed.
As the authors note, 2-4 days of antibiotic can successfully treat a UTI in children 3 months of age or older with lower tract infection only, so stopping antibiotics for patients who are prescribed a 7-10 day course is critical stewardship.3,4 Their initiative increased local attention to several issues related to prescribing for UTIs, and several new QI initiatives were started at their institution following this published study, including one to “optimize antibiotic choice and duration.” I will look forward to reading the results of that project!
1. Butler CC, O’Brien K, Pickles T, et al. Childhood urinary tract infection in primary care: a prospective observational study of prevalence, diagnosis, treatment, and recovery. The British Journal of General Practice. 2015;65(633):e217-e223. doi:10.3399/bjgp15X684361.b
2. Hay AD, Sterne JAC, Hood K, et al. Improving the Diagnosis and Treatment of Urinary Tract Infection in Young Children in Primary Care: Results from the DUTY Prospective Diagnostic Cohort Study. Annals of Family Medicine. 2016;14(4):325-336. doi:10.1370/afm.1954.
3. National Institute for Health and Care Excellence. Guideline for Urinary Tract Management in under 16s: diagnosis and management. https://www.nice.org.uk/guidance/cg54/chapter/1-Guidance#acute-management (accessed 2/28/2017).
4. Michael M, Hodson EM, Craig JC, Martin S, Moyer VA. Short versus standard duration oral antibiotic therapy for acute urinary tract infection in children. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD003966. DOI: 10.1002/14651858.CD003966.