Reviewed by: Leah Mische, M.D., Medical College of Wisconsin
Bottomline: This article describes the efficacy of a diagnostic stewardship intervention that provided aggregate audit and feedback of preoperative urine culture orders to three surgical subspecialty teams at four VA hospitals.
This was a quasi-experimental prospective pre/post pilot study comparing number of urine cultures obtained pre-intervention (January-December 2022) to post-intervention (January-October 2023). Specifically, the intervention examined percent of pre-operative urine cultures obtained in asymptomatic patients by three subspecialty surgical teams (Neurosurgery, Orthopedic Surgery, Vascular Surgery). The study was conducted in four VA sites, two of whom had ongoing urine culture diagnostic stewardship interventions, but which were unrelated to pre-operative urine culture sampling specifically. Patient cases were included if there was a urine culture obtained within 30 days of surgery in the absence of signs or symptoms of infection.
Feedback was provided to each surgical subspecialty at each VA site. Each site had a co-investigator as a site champion. Feedback was provided to each surgical team in aggregate and was individualized based on the preferences of that team. In addition to information about urine culture ordering, the groups were also provided summarized evidence against the standard acquisition of pre-operative urine cultures and instead offered alternative infection prevention strategies.
There were a total of 5,508 eligible surgeries during the study period, 952 of which had pre-operative urine cultures obtained. Rates of urine culture acquisition varied drastically from site to site and subspecialty to subspecialty. For example, pre-intervention, the Neurosurgery teams ordered pre-operative urine cultures somewhere between 1%-79% of the time depending on the specific VA site. In total, prior to the intervention 20.7% of surgeries had a pre-operative urine culture while post-intervention, this dropped to 12.9%, a statistically significant decline. Two of the VA sites had a statistically significant drop in urine culture orders. Interesting, one of the sites had a non-statistically significant 14% increase in urine culture acquisition. Of the three subspecialties, Orthopedic Surgery had the greatest decline in ordering pre-operative urine cultures across all four sites.
This study was limited by no clinical outcomes data. Additionally, it is interesting that one of the sites had a non-statistically significant increase in urine culture ordering, although mediated almost exclusively by one surgical team. Overall, this study did show that audit and feedback provided at an aggregate division level in surgical subspecialties may be a successful diagnostic stewardship intervention in the right setting.
Reference:
Parmasad V, Gupta K, O’Brien WJ, Drekonja D, Lira GJB, O’Neil S, Amundson C, Sikandar S, Morgan A, Strymish J, Chan J, Brown ME, Schweizer ML. An education with audit and targeted feedback intervention to de-implement preoperative surgical urine cultures: a multi-center quasi-experimental study. Infect Control Hosp Epidemiol. 2026 Jun 5:1-4. doi: 10.1017/ice.2026.10470. Epub ahead of print. PMID: 42244210.