# Diagnostic Stewardship as a 'nudge' to reduce inappropriate antibiotic use for urinary tract infections

> **NIH VA I01** · BALTIMORE VA MEDICAL CENTER · 2024 · —

## Abstract

Background: Antibiotic-resistant bacteria are estimated by the Centers for Disease Control and
Prevention (CDC) to kill over 23,000 Americans yearly. Overuse of antibiotics is a leading cause, and
reducing unnecessary antibiotic use is a national priority. A major factor in antibiotic overuse is
inappropriate or unnecessary culturing, particularly unnecessary urine culturing that identifies
colonization and leads to overdiagnosis of urinary tract infections (UTI).
Significance/ Impact: Diagnostic stewardship is a novel approach to limiting antibiotic use by modifying the
ordering, processing, or reporting of a “positive” culture that generally should not be treated. In preliminary
work, we found significant reductions in unnecessary urine cultures and associated antibiotic use through
diagnostic stewardship. Diagnostic stewardship is synergistic with antimicrobial stewardship by improving the
value and accuracy of urine testing before treatment. This proposal addresses gaps including: Defining best
UTI diagnostic stewardship methods, informed by experts and clinicians; developing implementation
methods for UTI diagnostic stewardship; and, assessing the impact of real life UTI diagnostic stewardship—
both benefits and any harms across acute-care, long-term care, and ambulatory care. This meets HSR&D
Research priorities of quality/safety, health care value, cross-cutting HSR methods priorities of
implementation science/provider behavior and ORD-wide priority of real-world impact of VA research in
addition to national priorities from CDC, Centers for Medicare and Medicaid Services (CMS) and the
President’s National Action Plan for Combating Antibiotic-Resistant Bacteria (CARB).
Innovation: Modifying how tests are ordered, processed, and reported can help improve patient care by
using existing technology more effectively. This is a ‘nudge’ approach, developed from psychology and
behavioral economics. This work uses the electronic medical record (EMR) in an innovative, mostly behind
the scenes fashion to improve appropriateness of ordering and reporting of tests. A pragmatic proof-of-
concept study within an existing network of VA health care systems, using automated outcomes from the VA
Corporate Data Warehouse (CDW) is efficient and consistent with the VA goal of being a Learning Health
System.
Our aims are as follows:
Aim 1: Define best UTI diagnostic stewardship criteria, based on literature and Delphi method expert panel.
Aim 2: Use iterative user-centered design process to develop EMR interface and lab protocols, with
clinicians and other stakeholders (nurses, doctors, technicians, and IT representatives).
Aim 3: Conduct a pragmatic proof-of-concept hybrid effectiveness implementation study of the UTI
diagnostic stewardship interventions in 3 CDC-CREATE Network Healthcare Systems evaluating benefits
and any adverse events.
Project Methods: Aims 1 and 2 will use expert panels for developing consensus criteria and a user-centered
design process, i...

## Key facts

- **NIH application ID:** 10728331
- **Project number:** 5I01HX002906-04
- **Recipient organization:** BALTIMORE VA MEDICAL CENTER
- **Principal Investigator:** Daniel J Morgan
- **Activity code:** I01 (R01, R21, SBIR, etc.)
- **Funding institute:** VA
- **Fiscal year:** 2024
- **Award amount:** —
- **Award type:** 5
- **Project period:** 2020-10-01 → 2025-09-30

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10728331

## Citation

> US National Institutes of Health, RePORTER application 10728331, Diagnostic Stewardship as a 'nudge' to reduce inappropriate antibiotic use for urinary tract infections (5I01HX002906-04). Retrieved via AI Analytics 2026-05-21 from https://api.ai-analytics.org/grant/nih/10728331. Licensed CC0.

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