Background: Urinary tract infections (UTI) are common in the outpatient setting and a key focus of antimicrobial stewardship efforts. Inappropriate antibiotic prescribing persists, including low utilization of first-line agents. Limited research exists evaluating the drivers of variations in antibiotic prescribing for UTI. This analysis assessed associations between patient, clinician, and neighborhood factors and receipt of a first-line antibiotic for UTI. Methods: A cross-sectional analysis of adult (18 and over) urgent care visits from January 2023 to April 2025 in an integrated academic healthcare system was conducted, assessing antibiotic prescriptions for uncomplicated UTI visits. First-line antibiotics were defined as nitrofurantoin, trimethoprim-sulfamethoxazole, and fosfomycin according to IDSA clinical guidelines. Only visits associated with an antibiotic prescription were included in the analysis. Patient health status was assessed using the Charlson Comorbidity Index (CCI). Neighborhood factors were assessed using the Area Deprivation Index (ADI). Clustered logistic regression models were fit to assess factors associated with the likelihood of receiving first-line antibiotics. Results: A total of 13,092 UTI visits were included, of which 58% received first-line antibiotics. Patients were primarily White (73.7%), female (89.4%), and used commercial insurance (56.9%). The average age was 54.1 years, and the average CCI was 1.9. Age was associated with a lower likelihood of receiving first-line therapy; each additional year of age (<18) was associated with a 1% decrease in odds (Adjusted Odds Ratio (aOR) = 0.99, 95% CI = 0.98, 0.99). Similarly, each one-point increase in CCI decreased the likelihood of receiving first-line antibiotics by 4% (aOR = 0.96, 95% CI = 0.94, 0.97). Compared with men, women were less likely to receive first-line antibiotics (aOR=0.55, 95% CI=0.48, 0.62). Treatment by a physician assistant (PA) (aOR=0.91, 95%CI=0.83, 0.98) or a registered nurse (APRN) (aOR=0.66, 95%CI=0.60, 0.73) was associated with a reduced likelihood of first-line medication. Finally, being on Medicaid (aOR=0.82, 95% CI=0.71, 0.94) or Medicare (aOR=0.82, 95% CI=0.73, 0.91) was associated with a decreased likelihood of receiving first-line antibiotics. No statistically significant association was found between living in a more disadvantaged neighborhood, as measured by the ADI, and receiving first-line antibiotics. Discussion: Being older, female, in poorer health, treated by a PA or APRN, or having Medicare/Medicaid were associated with a lower likelihood of receiving first-line antibiotics for UTI. These findings provide critical information to understand variations in antibiotic prescribing for UTI. Further work is needed to identify the drivers of these differences to improve equity in stewardship.

Background: Guideline-concordant, first-line antibiotic prescribing is a core antimicrobial stewardship strategy to reduce unnecessary broad-spectrum use, antibiotic resistance, and adverse events. Community-acquired pneumonia (CAP) is a common indication for outpatient antibiotics, yet first-line prescribing patterns and equity remain understudied. This analysis assessed associations between first-line prescribing and patient, clinician, and community characteristics in urgent care settings. Methods: Electronic health records from 28 urgent care clinics within an integrated academic healthcare system (January 2023–April 2025) were analyzed. Adults (18+ years) with pneumonia diagnoses and at least one prescribed antibiotic were included. ‘Community-acquired pneumonia’ refers to pneumonia diagnosed in urgent care, though some cases may not meet formal CAP criteria. Episodes were classified by first-line use (CAP without comorbidities: amoxicillin or doxycycline; CAP with comorbidities: either amoxicillin/clavulanate plus doxycycline or a macrolide, or respiratory fluoroquinolone monotherapy). Cluster-adjusted logistic regression assessed differences in first-line prescribing by patient, clinician, and community factors. Results: Among 9,670 episodes (4,966 no comorbidities), first-line prescribing occurred in 90.8% of CAP with no comorbidities and 54.4% of CAP with comorbidities. Mean age was 48.4 years (SD 17.4) for patients without comorbidities and 60.7 years (SD 17.5) for patients with comorbidities; 23% and 48% of episodes occurred among adults ≥65 years. The most common non–first-line antibiotics were amoxicillin-clavulanate and clindamycin, for CAP with and without comorbidities respectively. For CAP without comorbidities, fully adjusted models showed higher odds of first-line prescribing for episodes managed by Advanced Practice Registered Nurses (APRNs) compared to physicians and lower odds among patients with higher neighborhood disadvantage (ADI 26–49 vs 1–25 percentile) as seen in Figure 1. The Area Deprivation Index (ADI) quantifies neighborhood socioeconomic disadvantage (1-100 is least to most disadvantaged). For CAP with comorbidities, Black and Hispanic patients (vs. White) and those treated by APRNs (vs. physicians) had higher odds of receiving first-line antibiotics, while patients in neighborhoods with higher ADI scores had lower odds (vs. 1–25 percentile; Figure 1). Across both groups, no differences were observed by age, gender, or payer. Conclusion: First-line prescribing for outpatient CAP was high among patients without comorbidities but substantially lower among those with comorbidities, with disparities by clinician type, race/ethnicity (comorbidities only), and neighborhood deprivation. These findings reveal systemic inequities in antibiotic stewardship and reinforce the need for equity-focused strategies to support guideline-concordant prescribing. Additional work is warranted to clarify prescribing variation and evaluate relevant modifiers.

Asymptomatic bacteriuria (ASB) frequently results in inappropriate antimicrobial use. Urinalysis (UA)-driven reflex urine culture order sets can reduce inappropriate urine cultures. Most special indications on free text overrides within a (UA)-driven reflex culture protocol were inappropriately defined and rarely symptom-based. Eliminating the “other” indication could strengthen diagnostic stewardship and reduce unnecessary urine cultures.

Urinary tract infections (UTI) are common and women with typical symptoms may be treated empirically without culture. We evaluated the utility of urine culture in men presenting with typical symptoms of uncomplicated UTI. Most pathogens isolated retained susceptibility to first-line antimicrobials suggesting urine cultures may be unnecessary in this population.

Ambulatory antibiotic stewardship has traditionally focused on acute respiratory infections with few studies evaluating metrics for other commonly encountered ambulatory conditions, including urinary tract infections (UTI). We describe the development and validation of an electronically captured appropriate antibiotic use metric for ambulatory UTIs using coding data.

Our institution sought to evaluate our antimicrobial stewardship empiric treatment recommendations for Salmonella. Results from 36 isolates demonstrated reduced susceptibilities to fluoroquinolones with 1 isolate susceptible only to ceftriaxone. Analysis supports the current recommendation of empiric ceftriaxone therapy for severe infection and updated recommendation for sulfamethoxazole-trimethoprim in non-severe infections.

Background: Asymptomatic bacteriuria (ASB) is a widespread problem in hospitalized patients in which only a small subset of patients benefit from treatment. Other patient populations with ASB are harmed by treatment. In 2014, our institution implemented a urinalysis (UA)-driven reflex culture protocol which evaluated patient symptoms, risk factors, and the UA to determine whether bacterial culture was performed (Fig. 1). The goal of this process was to ensure that urine cultures were only performed in those patients who had symptoms of UTI and an abnormal urinalysis while allowing for exceptions in populations where treatment of ASB may be appropriate (ie, pregnancy, aged <3 years, impending urologic surgery, kidney transplant) or where the urinalysis may not be useful in determining whether infection is present (ie, neutropenia). An “other” indication with free-text documentation required was included to allow for unique situations. We evaluated the free-text option to determine whether additional indications were needed and whether data entered were medically appropriate. Methods: This retrospective review at a Midwestern, tertiary-care, academic medical center included inpatient UA with UTI evaluation order sets between July 1, 2020, and June 30, 2022. Descriptive statistics analyzed order-set utilization. Results: In total, 35,469 “urinalysis to reflex culture” order sets were submitted, of which 9,493 resulted in culture. Of these, 839 (8.8%) were ordered with an indication of “other.” “Other” was the most cited indication for special population override contributing to 40% (n = 839 of 2,085) of these indications, followed by kidney or pancreas transplant (29%) and neutropenia (13%). The write-in options fell into 1 of 11 themes (Fig. 2). The 3 most common reasons a urine culture was obtained using the free-text option were nonurologic surgical intervention (n = 223 of 839), immunosuppression not otherwise defined (n = 195 of 839), and symptom presence (n = 146 of 839). Based on current literature, 97% of other indications were inappropriate (n = 816 of 839). If the UTI protocol had been strictly followed, 696 of 839 (83%) cultures ordered with an indication of “other” would not have been obtained, due either to lack of symptoms or, if symptomatic, lack of pyuria. Conclusions: Most cultures obtained by selecting the “other” special population option on the algorithm were obtained in situations in which a urine culture was unnecessary. Removing the “other” indication from the algorithm may improve appropriateness of urine culturing with a possible decrease in CA-UTI and treatment of ASB. Although most write in rationales were inappropriate, adding an additional category for deceased donor-organ evaluation would be reasonable.

Disclosures: None