Unnecessary Antibiotic Prescribing in Children Evaluated for Urinary Tract Infection
Catherine S. Forster, MD1, Allison Loechtenfeldt, BA2, Samir S. Shah, MD2, Stuart L. Goldstein, MD2.
1Children's National Medical Center, Washington, DC, USA, 2CincinnatI Children's Hospital Medical Center, Cincinnati, OH, USA.
Background: The diagnosis of urinary tract infections (UTI) relies on culture results, which are not available at the point of care. Therefore, clinicians empirically treat UTIs based on the combination of urinalysis (UA) results and symptoms, which may result in antibiotic overuse. The objective of this study was to determine the rate and predictors of unnecessary antibiotic use in children evaluated for UTI.
Methods: Cross-sectional study of children < 5 years of age who presented to Primary Care, Urgent Care, or the Emergency Department at a single center from 9/2016-12/2017 and had a UA and urine microscopy to evaluate for UTI. Children with complex chronic conditions, abnormalities of the genitourinary tract (low grade vesicoureteral reflux (VUR) was not excluded), or those who were receiving antibiotics for treatment of an infection were excluded, as were patients in whom there was no documented concern for UTI. Patients were divided into 4 groups: 1) necessary treatment, antibiotic prescription in those with confirmed UTI, 2) unnecessary treatment, antibiotic prescription in those without UTI, 4) untreated UTI and 3) no UTI, no treatment. UTI was defined as >50,000 colony-forming units of a uropathogen plus pyuria, >5 urinary white blood cells per high powered field. Chi-square was used to compare categorical variables, t-test to compare continuous variables. Logistic regression was used to identify factors associated with unnecessary treatment.
Results: 468 patients were included: 184 (39.3%) received necessary treatment, 176 (37.6%) received unnecessary treatment, 3 (0.6%) had untreated UTIs, and 105 (22.4%) did not have a UTI and did not receive treatment. There were no differences in age, gender, or history of UTI or VUR between groups. In the univariate analysis, there were differences in proportion of children with fever and urinary frequency, but no other symptoms, between groups (Table 1). More children in the necessary treatment group had positive nitrites and > trace leukocyte esterase compared to both unnecessary treatment and no UTI, no treatment. There were more children with pyuria in the unnecessary treatment group compared to no UTI, no treatment, and in the necessary treatment group compared to all other groups (Table 1). In the multivariate analysis, only pyuria was significantly associated with increased odds of unnecessary treatment (OR 1.46 (1.28-1.67), while positive nitrites was associated with decreased odds of unnecessary treatment (OR 0.63 (0.57-0.70).
Conclusion: 49% of children <5 years who received antibiotics at the point of care for UTI did not have a UTI. Pyuria is associated with unnecessary treatment, while nitrites is associated with necessary treatment. A high pre-test probability should be present when evaluating a child for a UTI.
Table 1: Demographics, Presenting Symptoms, and Urinalysis Results
| Necessary Treatment (n=184) | Unnecessary Treatment (n=176) | Untreated UTI (n=3) | No UTI, No Treatment (n=105) | |
| Age (year) | 2.4 (1.5) | 2.3 (1.6) | 2.5 (2.0) | 2.7 (1.6) |
| Female | 173 (94.0) | 176 (94.3) | 3 (100) | 93 (88.6) |
| History of UTI | 37 (20.1) | 30 (17.6) | 2 (66.7) | 13 (12.4) |
| History of VUR | 7 (3.8) | 3 (1.7) | 0 (0) | 1 (0.9) |
| Fever | 110 (59.8)b | 109 (61.9)b | 2 (66.7) | 36 (34.2) |
| Dysuria | 45 (24.4) | 57 (32.3) | 2 (66.7) | 26 (24.7) |
| Vomiting | 32 (17.4) | 38 (21.6) | 0 (0) | 20 (27.6) |
| Abdominal pain | 29 (15.8) | 25 (14.2) | 0 (0) | 17(16.2) |
| URI symptoms | 17 (9.2) | 24 (13.6) | 1 (33.3) | 11 (10.5) |
| Frequency | 16 (8.7) | 14 (8.0)a | 1 (33.3) | 3 (2.9)a |
| Catheter Sample | 95 (51.6)b | 81 (46.0)b | 1 (33.3) | 30 (28.6) |
| Bagged Sample | 4 (2.2) | 4 (2.3) | 0 (0) | 1 (1.0) |
| Clean Catch | 85 (46.2)b | 87 (49.4)b | 2 (66.7) | 69 (65.7) |
| Nitrites | 93 (50.5)b,c | 7 (4.0) | 0 (0) | 0 (0) |
| Pyuria | 183(99.5)a,b,c | 167 (94.9)b | 2 (66.7) | 52 (49.5) |
| > Trace LE | 173 (94.0)b,c | 150 (85.3) | 2 (66.7) | 85 (81.0) |
a. p<0.05 compared to Untreated UTI, b. p<0.05 compared to No UTI, No Treatment
c. p<0.05 compared to Unnecessary Treatment, data presented as: n(%),
UTI: Urinary Tract Infection; VUR: Vesicoureteral Reflux; URI: Upper Respiratory Infection
LE: Leukocyte Esterase
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