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Aim Low-value care (LVC) is common. We aimed, using infants presenting to a major tertiary paediatric hospital with bronchiolitis between April 2016 and July 2018, to: (i) assess rates of chest X-ray (CXR) and medication use; (ii) identify associated factors; and (iii) measure the harm of not performing these practices. Methods We extracted data from the electronic medical record for all children aged 1-12 months given a diagnosis of bronchiolitis in the emergency department. Factors potentially associated with LVC practices were extracted, including patient demographics, ordering physician characteristics, order indication, medications prescribed and admission ward. To assess for harm, a radiologist, blinded to CXR indication, reviewed all CXRs ordered over the winter of 2017 for infants with bronchiolitis. Results A CXR was ordered for 439 (11.2%) infants, most commonly to rule out consolidation and collapse (65%). CXRs were more likely to be ordered for admitted infants (40.9% admitted to the general medical ward), and 62% were ordered by emergency department staff. Salbutamol was prescribed for 9.3% (n = 199). Amongst those who had a CXR, 28% were prescribed an antibiotic compared to 2.1% for those who did not. In an audit of 98 CXRs ordered over the winter of 2017, there were no CXR findings that meaningfully affected patient outcomes. Conclusion Using electronic medical record data, we found that CXR and medication use in bronchiolitis were higher than expected given our hospital guideline advice. Future research needs to understand why and develop interventions to reduce LVC.

Background Febrile UTI/pyelonephritis is a common diagnosis for children presenting to the Emergency Department (ED). A Cochrane review of the management of pyelonephritis in children showed no difference between intravenous (IV) and oral antibiotics. Despite this, many children are treated with at least initial IV antibiotics. The reasons are often unclear and it is uncertain whether this is appropriate as the Cochrane review excluded children at the worse end of the clinical spectrum. Our aim was to determine why physicians made these decisions as a first step in determining whether this is necessary. Methods A prospective observational study of children presenting to the ED at the Royal Children’s Hospital with UTI/pyelonephritis from Oct 2016 – Apr 2017. Data collection included demographic, clinical features, microbiology, treatment and outcomes. ED physicians were asked to record reasons for prescribing IV antibiotics and for treating the patient in hospital vs. in hospital-in-the-home (HITH). Results 170 children were included, 123 (72%) were treated with oral antibiotics, 43 (25%) IV and 4 (3%) intramuscular – these are now included in the IV group. In the IV group, 32 (19%) were admitted, 3 (2%) were transferred directly to HITH from ED and 13 had a single dose of IV antibiotics in ED and were discharged. A comparison of the clinically significant features between the two groups is outlined (Table 1). The commonest reasons cited for using IV antibiotics and for hospital admission vs. HITH is shown (fig 1 and 2). Conclusion This is the first study of decision-making for IV antibiotics and hospital admission for UTI/pyelonephritis in children. The fact that the reasons cited for IV antibiotics were often not evident on objective clinical data suggests that there may be overuse of IV antibiotics. We will present an assessment of appropriateness and suggest alternatives to the traditional IV and hospital admission route. Disclosures All authors: No reported disclosures.

Background A 2014 Cochrane review of acute UTI/pyelonephritis in children reported no difference between intravenous (IV) and oral (PO) antibiotics and the AAP recommends the routes as equally efficacious. Despite this, many children continue to be treated with IV antibiotics, with the appropriateness of this unclear. The Cochrane review was based on studies that excluded children with features including vomiting, urological abnormality, previous UTI, or pre-treatment with antibiotics. We aimed to compare: PO vs. IV antibiotics; 1 vs. 2–3 days IV antibiotics; and all patients compared with those in the Cochrane review. Methods A prospective observational study of children presenting to the ED at a tertiary children’s hospital in Australia with UTI/pyelonephritis from May 2016 to November 2017. Data included demographic, clinical features, microbiology, treatment and outcomes. Key features and outcomes were compared. Results Of 541 children, 378 (70%) received PO antibiotics and 163 (30%) IV/IM. Patients were significantly more likely to receive IV antibiotics if they presented with fever, vomiting, rigors or lethargy, had a history of previous UTI, or were pre-treated with PO antibiotics (P < 0.05). Of those treated with IV antibiotics, the majority received 1 (38%) or 2 (36%) days prior to PO switch. The only difference in those treated at with 1-day vs. 2–3 days of IV antibiotics was the proportion receiving maintenance IV fluids (table). A substantial number of our patients (n = 390, 72%) had a urological abnormality, vomiting, previous UTI or were pre-treated with PO antibiotics and therefore the Cochrane recommendations are not applicable. Table: 1 vs. 2–3 days IV antibiotics 1 day IV 2–3 days IV P values No. (%) No. (%) Total patients 64 (39) 74 (45) Age Mean 4.8 4.3 0.55 Fever 52 (81) 61 (80) 0.88 Vomiting 29 (45) 45 (59) 0.10 Urological abnormality 9 (15) 19 (26) 0.12 Maintenance fluids 13 (21) 33 (45) 0.003 Readmission 5 (8) 3 (4) 0.47 Conclusion Patients treated with initial IV appear different from those treated with PO antibiotics. However, 1 vs. 2–3 days IV appeared to be similar, suggesting an opportunity for shortening duration. We have provided the first prospective data since the Cochrane review in patients not included in it, showing the gap in evidence. Disclosures All authors: No reported disclosures.