Outcomes associated with initial narrow-spectrum versus broad-spectrum antibiotics in children hospitalized with urinary tract infections

Abstract

Objective: The aim of this study is to describe the proportion of children hospitalized with urinary tract infections (UTIs) who receive initial narrow- versus broad-spectrum antibiotics across children's hospitals and explore whether the use of initial narrow-spectrum antibiotics is associated with different outcomes.

Design, setting and participants: We performed a retrospective cohort analysis of children aged 2 months to 17 years hospitalized with UTI (inclusive of pyelonephritis) using the Pediatric Health Information System (PHIS) database.

Main outcome and measures: We analyzed the proportions of children initially receiving narrow- versus broad-spectrum antibiotics; additionally, we compiled antibiogram data for common uropathogenic organisms from participating hospitals to compare with the observed antibiotic susceptibility patterns. We examined the association of antibiotic type with adjusted outcomes including length of stay (LOS), costs, and 7- and 30-day emergency department (ED) revisits and hospital readmissions.

Results: We identified 10,740 hospitalizations for UTI across 39 hospitals. Approximately 5% of encounters demonstrated initial narrow-spectrum antibiotics, with hospital-level narrow-spectrum use ranging from <1% to 25%. Approximately 80% of hospital antibiograms demonstrated >80% Escherichia coli susceptibility to cefazolin. In adjusted models, those who received initial narrow-spectrum antibiotics had shorter LOS (narrow-spectrum: 33.1 [95% confidence interval; CI]: 30.8-35.4] h vs. broad-spectrum: 46.1 [95% CI: 44.1-48.2] h) and reduced costs (narrow-spectrum: $4570 [$3751-5568] versus broad-spectrum: $5699 [$5005-$6491]). There were no differences in ED revisits or hospital readmissions. In summary, children's hospitals have low rates of narrow-spectrum antibiotic use for UTIs despite many reporting high rates of cefazolin-susceptible E. coli. These findings, coupled with the observed decreased LOS and costs among those receiving narrow-spectrum antibiotics, highlight potential antibiotic stewardship opportunities.

FIGURE 1

Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) diagram. ICU, intensive care unit; UTI, urinary tract infection.

FIGURE 2

Variation in narrow-spectrum antibiotic use for urinary tract infection (UTI) across children’s hospitals. Volume in the above figure represents the volume of included UTI cases by hospital. % Narrow-spectrum represents the percentage of included UTI cases receiving a narrow-spectrum antibiotic. Error bars represent the 95% confidence interval (CI). Pearson’s correlation was utilized to examine the association of UTI case volume and the percentage of narrow-spectrum antibiotic use.

FIGURE 3

Hospital-level percent narrow-spectrum antibiotic use for urinary tract infection (UTI) compared with the proportion of Escherichia. coli isolates that were reported as susceptible to cefazolin. Hospitals are labeled consistent with Figure 2. Data are not presented for four hospitals (21, 27, 38, 39) due to a lack of submission of antibiogram data.