Implementation of Diagnostic Stewardship to Improve Urinary Tract Infection Antibiotic Use Across Three Medical Centers.

Claeys KC, Brown CH, Pineles L, Evans CT, Cao L, Trautner BW, Crnich CJ, Balasubramanian P, Ewers T, Gupta K, Strymish JM, Cadena J, O'Neil S, Krein SL, Coffey KC, Morgan DJ. Implementation of Diagnostic Stewardship to Improve Urinary Tract Infection Antibiotic Use Across Three Medical Centers. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2025 Jul 26 DOI: 10.1093/cid/ciaf411.

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Abstract:

BACKGROUND: Overdiagnosis of urinary tract infections (UTIs) and unnecessary antibiotics are common. This is particularly true in older adult populations such as Veterans. Diagnostic stewardship can decrease overdiagnosis and overtreatment, but optimal implementation of such interventions has not been fully studied. METHODS: This was a multicenter hybrid type two effectiveness-implementation study of UTI diagnostic stewardship interventions at three participating VA hospitals. Each hospital implemented one intervention at either the ordering, processing (conditional reflex urine culturing) or reporting stage. The primary outcome was inpatient UTI antibiotic days of therapy (DOTs) per admission evaluated using generalized estimating equations. Secondary outcomes included rates of urine cultures ordered and performed and, a safety measure of secondary bacteremia from a uropathogen. RESULTS: 37,085 hospital admissions occurred in the pre-intervention phase and 17,221 in the post-intervention phase. Of these, 6,914 (12.7%) included UTI antibiotics. Hospital 3, which implemented conditional reflex urine culturing had a 39.5% reduction in UTI DOT (95% confidence interval (CI), 13.9%, 57.5%) in the year following the intervention. Additionally, hospital 3 noted fewer urine cultures ordered (22.8% immediate and 35.7% slope reduction) and performed (38.9% immediate and 38.8% slope reduction). No change in UTI DOT was observed for ordering or results reporting interventions at other hospitals. There was no difference in the safety measure of uropathogen bacteremia. CONCLUSIONS: Conditional reflex urine culturing had a large decrease on UTI antibiotic DOTs and urine cultures performed. Health-systems or medical centers starting urine culture diagnostic stewardship should implement conditional reflex urine culturing first.