Clinical impact of a rapid urine diagnostic algorithm combined with antimicrobial stewardship in patients with...

Early appropriate antimicrobial therapy is a key determinant of outcome in sepsis, yet conventional urine culture takes 24-48 hours. We evaluated the clinical impact of a rapid microbiological algorithm applied directly to urine, combined with antimicrobial stewardship, in patients with suspected urinary sepsis.

Prospective quasi-experimental two-phase cohort study at a tertiary hospital. In adults with simultaneous urine and blood cultures, an initial observational phase formed the comparison cohort (conventional culture), and a second phase the intervention cohort, in which urine underwent Gram stain, laser-nephelometry growth detection (Alfred 60/AST), MALDI-TOF-MS identification, rapid susceptibility testing, and immunochromatographic ESBL and carbapenemase detection, with immediate reporting and recommendations by an infectious diseases specialist. Multivariable models (logistic and negative binomial) were adjusted for age, sex, Charlson index, department and qSOFA.

We included 594 patients (297 per cohort). The algorithm achieved organism identification in 92.6% of cases, with a median turnaround time of 7.25 versus 75.0 hours (p<0.001), and 98.6% agreement with culture. Overall mortality was 6.1% versus 11.1% (p=0.039). After adjustment, the intervention was associated with significant reductions in hospital stay (IRR 0.82; p=0.012), days of therapy (IRR 0.79; p<0.001), intravenous antibiotics (IRR 0.83; p=0.001), need for ICU admission (OR 0.42; p=0.003) and overall mortality (OR 0.44; p=0.011).

A rapid urine diagnostic algorithm, integrated with an expert stewardship intervention, was associated with lower antibiotic consumption and improved outcomes in suspected urinary sepsis. Combining rapid diagnostics with expert advice appears key to translating microbiological information into effective therapeutic decisions.