Improving urine testing stewardship with a technology-leveraged urine testing guideline

Unnecessary urine cultures contribute to inappropriate antibiotic use, antimicrobial resistance, and Clostridioides difficile infection, particularly when asymptomatic bacteriuria (ASB) is misclassified as infection. We evaluated the diagnostic stewardship impact of an algorithm-based best practice alert (BPA) embedded in the electronic medical record (EMR) to guide urine testing in hospitalized adults.

This prospective quality improvement study was conducted at a 740-bed tertiary care hospital. The BPA triggered when urinalysis with reflex to culture (UACC) was ordered for patients admitted ≥48 hours, guiding clinicians through an algorithm-based ordering workflow. Monthly rates of UACC and pan-culturing were compared between a 12-month pre-intervention period and a 12-month post-intervention period using interrupted time series (ITS) and Mood's median two-sample test. Gram-negative rod (GNR) bacteremia rates were monitored for safety.

Urine testing decreased from 6.45 to 4.41 tests per 1,000 patient-days (31.6% reduction; P < .01), and pan-culturing decreased from 3.47 to 2.70 per 1,000 patient-days (22.2% reduction; P < .01). ITS showed declining trends both before and after implementation, without significant immediate changes in level or slope following the intervention. CAUTI rates remained stable (0.91 vs 0.82 per 1,000 catheter-days; P = .68), as did rates of gram-negative rod bacteremia (0.47 vs 0.70 per 1,000 patient-days; P = .22). Algorithm adherence averaged 63.9% and increased over time (P < .01). CAUTI cases classified as potential asymptomatic bacteriuria declined from 31.8% to 25.0% (P = .68).

An EMR-integrated, algorithm-based BPA coincided with sustained lower urine testing and pan-culturing rates without adverse safety signals within the context of existing downward trends. Ongoing monitoring is needed to sustain adoption and appropriate use.