Choosing Wisely: SickKids study leads to improved process for diagnosis and management of urinary tract infections (UTIs) in children

Urinary tract infections (UTIs) are a common bacterial cause of fevers in children and often lead to a visit to the doctor’s office or emergency department (ED). New research from The Hospital for Sick Children (SickKids) identifies a streamlined approach to help improve the accurate diagnosis of UTIs to reduce the strain on the health system and unnecessary use of antibiotics. 
 
The study was recently published in an article in Pediatrics authored by Dr. Olivia Ostrow, Staff Physician, Paediatric Emergency Medicine, and Associate Director of the Choosing Wisely program at SickKids. An improvement in antibiotic prescribing and appropriate use, also known as antimicrobial stewardship, is one of the focus areas of Choosing Wisely, an international campaign SickKids joined in 2016. Antimicrobial stewardship can help decrease antibiotic resistance, improve patient outcomes and health-care resource utilization.  
 
A confirmed UTI diagnosis can take up to 48 hours due to the turnaround time required for testing results, during which time patients may have already started antibiotic treatment. In addition, without an established follow-up process for negative test results, patients may not be consistently notified or told to stop taking antibiotics. 
 
Since 2017, in collaboration with SickKids’ Emergency Medicine, Infectious Diseases, and Microbiology departments, Ostrow led a quality improvement initiative with the goal of decreasing the misdiagnosis of paediatric UTIs by 50 per cent while improving antimicrobial stewardship in the ED. The initiative involved the development of a new UTI diagnostic algorithm and creating a dedicated nurse role for managing outstanding ED test results, including negative UTI tests with instructions to discontinue antibiotics.  
 
“The diagnostic algorithm was designed to guide clinicians whether to make a probable UTI diagnosis with an antibiotic prescription during the ED visit while cultures were pending, versus discharging without antibiotics while awaiting culture results,” Ostrow says. To integrate this streamlined approach into clinical care, posters of the algorithm were displayed in the ED and the SickKids intranet site, and later integrated into the electronic medical record system to assist with clinical decision-making at the point of care. 
   
From 2017 to 2021, UTI misdiagnosis decreased from 55 per cent to 26 per cent, and adherence to the recommended antibiotic use improved by 40 per cent. Furthermore, by implementing a system to call families of patients who tested negative, children avoided 2,128 days of unnecessary antibiotics. The improvements have been sustained through reminders, clinician education, and ongoing collaborations.

To ensure UTI cases weren’t being missed, positive results without a UTI diagnosis were reviewed for ED return visits or hospitalization. All patients were contacted to confirm their diagnosis and prescribed antibiotics as necessary, with only 14 patients returning to the ED within 72 hours.

“These strategies not only make it easier to provide better care, but support clinicians in providing children with the right care,” Ostrow says.