Can Electronic Clinical Decision Support Systems Improve the Diagnosis of Urinary Tract Infections?: A Systematic Review and Meta-Analysis

Abstract

Background Urinary tract infection (UTI) is a commonly misdiagnosed infectious condition. Stewardship interventions which successfully reduce rates of asymptomatic bacteriuria treatment (ASB) are often labor intensive, and thus a systematic solution is desirable. In this systematic review and meta-analysis, we aimed to identify published studies describing interventions utilizing clinical decision support (CDS) to reduce unnecessary urinary diagnostic testing and to characterize the effectiveness of these interventions. Methods We conducted a comprehensive electronic search and manual reference list review for peer-reviewed articles published prior to July 2, 2021. Studies which described an intervention designed to reduce unnecessary or incorrect diagnosis of UTI through utilization of CDS were included. The primary outcome of interest was rate of urine culture tests ordered. Results The electronic search identified 5,013 studies for screening. After screening and full-text review, 9 studies met criteria for inclusion. Manual reference list review identified an additional 5 studies, yielding a total of 14 studies included in the systematic review. The most common intervention was urinalysis with reflex to urine culture based on pre-specified urinalysis parameters, such as a threshold level of pyuria. All nine studies with statistical comparisons reported a decreased urine culture rate post-intervention, eight of which were statistically significant. In the meta-analysis, a 37.1% decrease in urine culture rate was detected after CDS implementation (Table 3). Several studies also reported improvements in antimicrobial-related measures such as days of therapy and guideline-concordant therapy. Catheter-associated urinary tract infection rate was decreased in two studies and unchanged in a third study. A limited number of included studies reported no adverse outcomes including increased bloodstream infection or mortality rates. Conclusions In this systematic review and meta-analysis, we found that clinical decision support was highly effective in decreasing urine culture rates. Prospective studies are needed to evaluate the impact on antimicrobial prescribing, patient-relevant outcomes, and potential adverse effects.

Leila S. Hojat

Assistant Professor of Medicine

My research interests include hospital epidemiology, antimicrobial resistance, and antimicrobial stewardship.