Implementation of Diagnostic Stewardship to Improve Urinary Tract Infection Antibiotic Use Across 3 Medical Centers

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.

This was a multicenter hybrid type 2 effectiveness-implementation study of UTI diagnostic stewardship interventions at 3 participating Veterans Administration hospitals. Each hospital implemented 1 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.

A total of 37 085 hospital admissions occurred in the preintervention phase and 17 221 in the postintervention phase. Of these, 6914 (12.7%) included UTI antibiotics. Hospital 3, which implemented conditional reflex urine culturing, had a 39.5% reduction in UTI DOT (95% confidence interval, 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.

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. Article Summary: A multicenter pragmatic pre-/poststudy in Veterans Administration hospitals found that conditional reflex urine culturing significantly reduced urinary tract infection antibiotic use and urine cultures without increasing bacteremia, highlighting its potential as a high-value diagnostic stewardship intervention among older hospitalized adults.