Major article|Articles in Press

Choosing wisely initiative for reducing urine cultures for asymptomatic bacteriuria and catheter-associated asymptomatic bacteriuria in an 11-hospital safety net system

Published:March 01, 2023DOI:


      • Two electronic health record interventions successfully reduced urine cultures by more than 20% in a large safety net system: a mandatory indication on urine culture and a best practice advisory for urine cultures on patients with urinary catheters.
      • No additional education or stewardship was implemented for this initiative.
      • Reductions in urine culture ordering rates and catheter associated urinary tract infection rates were highly variable among 11 different hospitals.



      Treatment of asymptomatic bacteriuria (ASB) is common. Overtreatment of ASB leads to harm, including adverse effects from antibiotics, antibiotic resistance, and increased length of stay.


      This quality improvement initiative targeted inappropriate urine cultures (UC) across 11 hospitals and 70 ambulatory clinics in a safety-net setting. A mandatory prompt for appropriate indications for UC orders and a best practice advisory (BPA) for UC on patients with urinary catheters were created. UC ordering was compared preintervention (June 2020-October 2021) to postintervention (December 2021-August 2022). Variation in hospitals and clinics were assessed, as well as BPA responses by clinician type and specialty.


      Inpatient UCs decreased 20.9% (p < .001), and outpatient UCs was unchanged (2.6% increase, nonsignificant). Inpatient UCs on patients with urinary catheters decreased 21.6% (p < .001). Temporal trends were also assessed. High variation was seen among hospitals and clinics. Low BPA acceptance rates were seen in internal medicine and family medicine clinicians. Attendings showed high acceptance to the BPA compared to other clinicians.


      This initiative successfully decreased UCs in a large, safety-net system. Further study is needed in assessing variation among hospitals and clinics, as well as among clinician types and specialties.


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