Diagnosis and Management of Urinary Tract Infections in Premature and Term Neonates: A Quality Improvement Project in a Level III Neonatal ICU
Authors: Bozzella Michael J , Johnson Heather , Pearce Kelly , Wu Allen , Laird Mary 
Published: January 2025

Abstract

Corresponding Author: Michael J Bozzella, DO, MS, Department of Pediatrics, Division of Infectious Diseases, University of Colorado, 13123 East 16th Avenue, Box 055, Aurora, CO 80045, USA. 617-817-5008, Michael.bozzella@childrenscolorado.org
Alternate Corresponding Author: Heather Johnson PharmD, BCPPS, Department of Pharmacy, Children’s Hospital Colorado, 4090 Briargate Parkway, Colorado Springs, CO 80920, USA, 719-305-4708, Heather.Johnson@childrenscolorado.org
No conflicts of interest

Background
Urinary Tract Infections (UTI) are common infectious concerns in the neonatal population. While diagnostic criteria are established in older children, diagnosis and treatment decisions often vary by provider for infants in the neonatal intensive care unit (NICU). In performing handshake antimicrobial stewardship in our NICU, we anecdotally noted this variation in practice. In collaboration with members of our Neonatology team, we began a quality improvement project centered on UTI diagnosis and management in our NICU. The following data summarizes our baseline work.

Methods
Data analyst support was utilized to obtain medical record numbers for all infants hospitalized in our NICU who had urine cultures collected during our time periods of interest. We then reviewed individual patient charts in the electronic medical record to assess for the following variables: presence of urinalysis, urinalysis results, urine culture results, presence of blood cultures, empiric antibiotic use, and UTI treatment history. To establish our baseline, we opted to look at a period of 1 year prior to the implementation of our Handshake Stewardship Program (July 2021 – July 2022), then 1 year after the implementation (July 2022 – July 2023). This base-line period (including both date ranges) would lead into the development of a NICU specific diagnostic algorithm. At the time of this abstract, data for the 13-month period of June 2022 through June 2023 was available for analysis. Urinalyses were considered positive if there were &gt;5 WBC per high powered field, or if urinary nitrite or leukocyte esterase were detected.

Results
For this 13-month period, 113 urine cultures were collected on 41 unique patients. 60 (53%) of those urine cultures had concurrent urinalysis (UA) performed (Figure). 18 UTIs were treated, of which 6 (33%) had negative UA, 3 (17%) had no concurrent UA, and 5 (28%) had ≤10K CFU of bacterial growth reported on semi-quantitative culture. 75 (66%) of the urine cultures had concurrent blood cultures obtained. 77 (68%) of urine cultures sent had empiric antibiotic agents started, and of that 77, 6 (8%) had antibiotic starts without a concurrent blood culture (Table).

Conclusions
In our NICU, there is high practice variation regarding the diagnostic approach and management of UTI. Additionally, infectious concerns lead to abundant use of antimicrobial agents, whose negative effects may have immediate impacts on our unit (i.e., increased incidence of resistant infections) and potential long-term impacts on the lives of our patients (i.e., concerns regarding the developing microbiome). This baseline data supports the development of a local treatment pathway and quality improvement initiative with the goals of increasing use of urinalysis with urine cultures and decreasing total antibiotic Days of Therapy in our NICU.

Table: Urine Culture (UCx), Urinalysis (UA), Blood Culture (BCx), and Antibiotic (Abx) starts by month