2824. 3rd Generation Cephalosporin (3rd CEP) Use and Antibiotic Selection Appropriateness for Uncomplicated Febrile Urinary Tract Infections (UTI) in Children

BACKGROUND: Concerns regarding antibiotic resistance have led many pediatricians to rely on 3(rd) CEP, namely ceftriaxone (CRO) and cefdinir (CDR), for UTI treatment. 3(rd) CEP use is a major risk factor for C. difficile infections and contribute to multidrug resistance. We sought to examine local prescribing patterns for uncomplicated febrile UTI in children to guide development of a standardized treatment pathway aimed at reducing unnecessary 3(rd) CEP use. METHODS: We conducted chart review of children aged 2 mo.-18 yrs treated at our institution for uncomplicated febrile UTI between Oct 2021 – Oct 2022. Subjects were identified by abnormal urine culture (UCx) regardless of colony-forming units (CFU) and included if they met a priori definition. Antibiotic selections were evaluated relative to urinalysis (UA), UCx, and bacterial susceptibilities to assess appropriateness of treatment. This project was certified by our institutional review board as quality improvement. RESULTS: 61 subjects were included (85% female; 3.8 yrs median age; 70%, 16%, 13% treated in ED only, ED/inpatient, inpatient only, respectively). CRO or CDR were most frequently given as initial in-house treatment (ED or inpatient) (Fig 1). 53% of subjects received ≥1 dose of CRO or CDR (ED, inpatient or discharge prescription). 31% of subjects (68% in ED only) were identified as misdiagnosed with UTI (e.g., bacterial growth below CFU threshold or suggestive of contaminant). Providers relied on urine test strips rather than UA/microscopy in 38% of cases misdiagnosed UTIs. Of those with confirmed UTI, E. coli was most common pathogen (81%) followed by other Gram-negative bacteria (14%); susceptibilities were reported in 97% (Fig 2). Initial antibiotic selection was deemed inappropriate in 68% (Fig 3); 39% received CRO/CDR unnecessarily. ≥5 white blood cells per high-power field was most associated with a confirmed UTI (P=0.004). [Figure: see text] [Figure: see text] [Figure: see text] CONCLUSION: Inappropriate 3(rd) CEP use and antibiotic overuse in general were prevalent in our study. The biggest drivers were UA underutilization contributing to UTI misdiagnosis and failure to use UCx to de-escalate antibiotics. Our findings serve as a foundation from which to build a standardized treatment pathway for uncomplicated febrile UTIs that will improve antibiotic stewardship and reduce 3(rd) CEP use. DISCLOSURES: Taylor Morrisette, PharmD, MPH, AbbVie: Advisor/Consultant|Basilea: Advisor/Consultant Ronald J. Teufel, II, MD, MSCR, Enanta Pharmaceaticals: Grant/Research Support|Health Resources and Servises Administration: Grant/Research Support|Moderna: Grant/Research Support|National Institute of Health: Grant/Research Support