Peer Comparison Improves Guideline Adherence for Urinary Tract Infection in a Military Emergency Department: A...

Given the threat of antimicrobial resistance, accrediting organizations require antimicrobial stewardship programs (ASPs) to create facility-specific guidelines (FSGs) for common infectious syndromes to improve patient outcomes. Personalized feedback with peer comparison (PC) can increase adherence to guidelines and reduce broad-spectrum antibiotic use. The emergency department (ED) is Wright-Patterson Medical Center's (WPMC) largest antibiotic prescriber for urinary tract and skin and soft-tissue infections (SSTI), and adherence to FSGs for management of urinary tract infection (UTI) is historically low despite accessible FSGs. We assessed the effects of monthly PC report cards on ED adherence to FSGs for UTI and SSTI, with community-acquired pneumonia (CAP) serving as a control syndrome, with the primary aim of improving UTI FSG adherence.

A quasi-experimental stepped-wedge intervention with monthly chart review was conducted from July 2023 through June 2024 regarding UTI, SSTI, and CAP management. A poster including the FSGs for UTI, SSTI, and CAP was displayed in the ED at the end of September 2023. Monthly de-anonymized PC report cards (individual names and scores visible to all 20 ED colleagues) of UTI FSG adherence were provided to the ED starting in January 2024, and SSTI encounters were added to the report in the following month. Patient demographics, FSG adherence scores (0.25 point per encounter for each correct criterion: diagnosis, antibiotic choice, antibiotic dose, antibiotic duration), UTI antibiogram, and syndrome resolution within 2 weeks were analyzed. Descriptive statistics were performed using Microsoft Excel version 2308. Bayesian and regression analyses were performed with "R" version 4.5.1. This project received a non-research (quality improvement) determination from the WPMC Human Protections Office.

568 ED encounters (295 UTI; 173 SSTI; 100 CAP) were reviewed. Median patient age was 55 years (IQR 34-70) and 68% were female (387/568). Mean FSG adherence scores changed for UTI and SSTI from 0.47 (SD 0.31) and 0.64 (SD 0.27) to 0.73 (SD 0.37) and 0.61 (SD 0.29), respectively, after PC. Before PC, cephalosporins were prescribed for 62% of UTIs (106/170); after PC, the most prescribed antibiotics were nitrofurantoin (51%, 64/125) and trimethoprim-sulfamethoxazole (18%, 22/125). In contrast to the poster display, for UTI management PC improved probability of correct medication (median 0.365, 95% highest posterior density interval [0.084, 0.648]), dosage (0.395 [0.118, 0.679]), and duration (0.473 [0.219, 0.728]). Each one-point improvement in adherence was associated with an estimated reduction in days of antibiotic therapy (DOT) for UTI (-1.4 days; 95% CrI: -2.030, -0.735) and SSTI (-4.36 days; 95% CrI: -6.063, -2.651) without reducing clinical resolution. Poster display alone did not improve adherence for any syndrome and FSG adherence for the control syndrome (CAP) did not change across study periods.

ED clinicians meaningfully increased their adherence to guideline-directed management of UTIs when publicly compared among their peers, safely reducing both the spectrum of prescribed antibiotics and DOT; increasing the availability of FSGs did not similarly increase guideline adherence. Sequentially phased peer-comparison feedback may serve as a scalable antimicrobial stewardship tool across the Military Health System and deployed environments.