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Background Urinary tract infections (UTIs) are the most common outpatient indication for antibiotics and an important target for antimicrobial stewardship (AS) activities. With The Joint Commission standards now requiring outpatient AS, data supporting effective strategies are needed. Methods We conducted a 2-phase, prospective, quasi-experimental study to estimate the effect of an outpatient AS intervention on guideline-concordant antibiotic prescribing in a primary care (PC) clinic and an urgent care (UC) clinic between August 2017 and July 2019. Phase 1 of the intervention included the development of clinic-specific antibiograms and UTI diagnosis and treatment guidelines, presented during educational sessions with clinic providers. Phase 2, consisting of routine clinic- and provider-specific feedback, began ~12 months after the initial education. The primary outcome was percentage of encounters with first- or second-line antibiotics prescribed according to clinic-specific guidelines and was assessed using an interrupted time series approach. Results Data were collected on 4724 distinct patients seen during 6318 UTI encounters. The percentage of guideline-concordant prescribing increased by 22% (95% CI, 12% to 32%) after Phase 1 education, but decreased by 0.5% every 2 weeks afterwards (95% CI, –0.9% to 0%). Following routine data feedback in Phase 2, guideline concordance stabilized, and significant further decline was not seen (–0.6%; 95% CI, –1.6% to 0.4%). This shift in prescribing patterns resulted in a 52% decrease in fluoroquinolone use. Conclusions Clinicians increased guideline-concordant prescribing, reduced UTI diagnoses, and limited use of high-collateral damage agents following this outpatient AS intervention. Routine data feedback was effective to maintain the response to the initial education.

Background Urinary tract infections (UTIs) are the most common outpatient indication for antibiotics and an excellent target for outpatient antimicrobial stewardship (AS) interventions. This study evaluated the impact of education and data feedback on outpatient UTI diagnosis and prescribing. Methods A clinic-specific antibiogram, diagnosis and treatment guideline, and educational session were provided at one urgent care (UC) and one primary care (PC) clinic in Durham, NC in August and November of 2017. Educators reviewed the appropriate diagnosis, treatment, and duration of therapy for UTIs, including avoidance of treatment for asymptomatic bacteriuria and choice of first-line agents with lower collateral damage. Adult encounters with a UTI diagnosis code from November 2016 to November 2017 and from August 2016 to August 2017 were included in the preintervention cohort for UC and PC, respectively. The postintervention cohort included encounters following education intervention in April 2018. Summary data of UTI diagnoses and guideline concordant prescriptions were fed back to clinics February 2018. The primary endpoint was proportion of first- or second-line antibiotic choice for UTI according to clinic-specific guidelines. Pre- and postintervention phase and trend changes were assessed by an interrupted time series approach. Results Data were collected on 2,660 and 1,016 UTI encounters at UC and PC, respectively. Guideline concordant prescribing increased at UC from 29% at baseline to 47% in the 5 months after the education and at PC from 54% at baseline to 62% in the 8 months after the education (Figures 1 and 2). The mean number of UTI diagnoses per month decreased at UC from 142 at baseline to 102 and at PC from 32 at baseline to 25 after the education. Conclusion Clinicians increased guideline concordant prescribing and reduced diagnosis rates for UTIs. AS is effective at improving guideline-directed diagnosis and management of UTIs in outpatient settings. Figure 1. Time series analysis of UTI visits with prescriptions for guideline concordant antibiotics at UC. Figure 2. Time series analysis of UTI visits with prescriptions for guideline concordant antibiotics at PC. Disclosures All authors: No reported disclosures.