Urinary Tract Infection Antibiotic Stewardship: Improving Follow-up in the Emergency Department

Urinary symptoms are among the most common reasons for presenting to the emergency department (ED). To diagnose a urinary tract infection (UTI) clinicians use a combination of history, symptoms, and urinalysis (UA). A urine culture (UC) is the gold standard for diagnosis of a UTI; however, this typically results 24-48 hours after the UA. This leads to situations where patients start on empiric antibiotics for a UTI prior to UC results. If the UC is negative, antibiotics should be discontinued as this leads to unnecessary antibiotic exposure. To develop and implement a protocol for follow-up management of negative UC results to reduce inappropriate antibiotic exposure at a free-standing pediatric ED. The focus was to improve UC follow-up rather than decreasing empiric prescriptions as an initial stewardship intervention.

Baseline data collection (1/2024—12/2024) to determine how many patients were prescribed empiric antibiotics for a UTI that had a negative UC, followed by a Plan-Do-Study-Act (PDSA) model with 2 intervention cycles. Cycle 1 (4/1/2025—5/3/2025) consisted of an ED physician educating advanced practice providers (APPs), who called parents/caregivers whose child was started on empiric antibiotics for a UTI whose UC was negative to discontinue antibiotics. Cycle 2 (6/1/2025-9/30/2025) involved the same intervention as cycle 1 but was performed by ED APPs only.

Baseline data (n=122) showed 57% (n=70) patients had a positive UC, 43% (n=52) had a negative UC, which averaged 4 patients per month with a negative UC that were started on empiric antibiotics for a UTI and had no follow-up in the ED. Cycle 1 showed 15 patients that were started on empiric antibiotics for a UTI that had a negative UC, 80% (n=12) of those patients were successfully called by an ED APP and discontinued antibiotics, 20% (n=3) were unable to be reached and did not stop their antibiotics. In cycle 2 there were 39 patients who were started on empiric antibiotics for a UTI with a negative UC, 74.36% (n=29) were successful callbacks from an ED APP and stopped their antibiotics, while 25.64% (n=10) were unable to be contacted and did not stop their antibiotics. Between the two cycles, this demonstrated a median success rate of 75.93%.

This shows that antibiotic stewardship in the ED is feasible and beneficial. Further study is needed to determine if other contact methods would improve success rates.