Evaluating the Impact of Order Set Implementation in Prescribing Practices for Pediatric Urinary Tract Infections Between a Non-academic and an Academic Children’s Hospital in the Inpatient General Pediatric Population
Authors: Allred Jessica , Courtney Ashleah , Clemente Adriana Sarmiento , Dahl Steven , McMinn Caleb , Vance Mary Kathryn , Maples Holly 
Published: January 2025

Abstract

Corresponding Author: Jessica Allred, Address: 4301 W. Markham St. Little Rock, AR 72205, 501-317-0634, jallred2@uams.edu
Alternate Corresponding Author: Holly Maples, 1 Children’s Way, Slot 208, 501-658-6796, maplesholly@uams.edu
Acknowledgments: Jeff and Kathy Lewis Sanders Distinguished Chair in Pediatrics Endowment
Conflict of Interest: All authors: No conflicts of interest.

Background
Pediatric urinary tract infection (UTI) continues to be one of the most prevalent infections in children. Unfortunately, antibiotic resistance continues to develop due to overuse of 3rd generation cephalosporins. The high prevalence of UTI’s in children in the face of increasing antibiotic resistance indicates that clinicians and public health experts face on-going challenges in prescribing antibiotics for children. Unfortunately, health disparities play a role in antibiotic prescribing and along with antibiotic resistance can be harmful to children.

Methods
This project aims to determine if two different pediatric medical centers prescribe similarly following order set implementation for race within their general peds population. A retrospective chart review of inpatient general pediatric patients who received an antibiotic prescription from two pediatric medical centers, one of which being academic (AC) and the other being non-academic (NAC) from January 1st, 2022 to December 31st, 2023 for the treatment of UTI. The order set was implemented on July 1, 2023. For inclusion criteria, the patient had to receive at least one antibiotic for a UTI and be ≤ 19 years of age. Intensive care, oncology, and patients with abnormal urology anatomy were excluded. Data collected included age, weight, gender, race, allergies, antibiotic choice, payor status, and duration. Data was analyzed descriptively and statistically via Wizard 2.0 Version 2.0.14. Data for black patients in NAC were not analyzed statistically due to small numbers. The results were summarized into percentages to easily compare race (Black, White, and Other) and chi-square statistical test was used on the categorical data with p&lt;0.05 being seen as significant.

Results
In AC a total of 1,786 patients with 1,313 pre-implementation [758 (57.1%) white, 281 (21.7%) black, and 274 (21.2%) other] and 493 post-implementation [295 (59.8%) white, 115 (23.3%) black, and 83 (16.8%) other] were analyzed. In NAC there a total of 733 patients with 557 pre-implementation [339 (60.9%) white, 11 (2%) black, and 282 (38.5%) other] and 176 post-implementation [90 (51.1%) white, 11 (6%) black, and 75 (42.6%) other] were analyzed.
Pre-implementation, 1st generation cephalosporin usage for white patients was 29.4% in AC and 19.2% in NAC. Post-implementation, 1st generation cephalosporin usage changed to 35.6% in AC (p=0.052) and 37.8% in NAC (p&lt;0.001). 3rd generation cephalosporin usage pre-implementation for white patients 48.2% in AC and 64.1% in NAC. Post-implementation this changed to 45.8% in AC (p=0.472) and 44.9% in NAC (p&lt;0.001)
Pre-implementation, 1st generation cephalosporin usage for black and other patients was 32% and 35% respectively in AC and 23.7% for other patients in NAC. Post-implementation, 1st generation cephalosporin usage changed to 27% (p=0.32) and 24.1% (p=0.062) in AC and 42.7% (p=0.002) in NAC. 3rd generation cephalosporin usage pre-implementation for black and other patients 42.3% and 54.4% in AC and 64.1% for other in NAC. Post- implementation this changed to 44.3% (p=0.715) and 53% (p=0.827) in AC and 45.4% (p=0.004) in NAC.

Conclusion
Despite the creation of an order set to aid with antibiotic selection, there are differences within the two hospitals within the same system for antibiotic prescribing practices including by race. While order set utilization was not high, education is thought to have impacted the differences seen the most. Future study will include addressing provider behaviors for utilizing pathway and order sets.