Purpose: According to the AAP Pediatric Urinary Tract Infection (UTI) Clinical Practice Guidelines Action Statement, the diagnosis of a UTI is made on the basis of quantitative urine culture results in addition to evidence of pyuria and/or bacteriuria. Urine cultures sent without evidence of pyuria or bacteriuria may lead to over-treatment of asymptomatic bacteriuria. The purpose of this study was to change ordering practices to decrease the number of unnecessary urine cultures performed. Methods: This pre-/post-intervention study included inpatient children >2 months and <18 years in a tertiary care children’s hospital and was determined by the institutional review board to be not regulated as human subjects research. An order set in the electronic health record was designed in collaboration with a university-wide committee recommending ordering a urinalysis (UA) with a reflex culture in place of both urinalysis and urine culture. This intervention excludes patients with genitourinary abnormalities, immunosuppression, absolute neutrophil count <500, pregnancy or renal transplant. Education to pediatric residents was provided in the form of a brief presentation explaining the project and order set. A retrospective chart review was performed in the inpatient setting 6 months prior to and following implementation of the order set. Duplicate tests performed on the same day and on the same patient were excluded. Descriptive analysis was performed with assessment of aggregate and monthly counts. Results: 125 UA with reflex cultures were ordered in the 6 months prior to implementation of the order set compared to 282 UA with reflex cultures were ordered in the 6 months following implementation (Figure 1). In the same time frames, the total number of urine cultures decreased from 851 urine cultures to 818 urine cultures. There was no change in patient census during the study time period. Conclusion: Simple order set changes with resident education were sufficient to change urine culture ordering practice by increasing the total number of UA with reflex culture ordered. There was an associated decrease in total number of urine cultures. Next steps include further chart review to ensure exclusion criteria were applied appropriately and no harm occurred due to delayed diagnosis of UTI.

Figure 1

Figure 1. Total number of UA with reflex cultures ordered by month. * Order set was implemented in February 2017.

Figure 1

Figure 1. Total number of UA with reflex cultures ordered by month. * Order set was implemented in February 2017.

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