Antibiotic prescribing appropriateness for urinary tract infections in a tertiary emergency department: a retrospective cohort study

Abstract Introduction Antibiotic misuse in emergency departments (EDs) drives antimicrobial resistance and adverse outcomes. This study assessed ED antibiotic prescribing adherence to hospital UTI guidelines at King Abdulaziz Medical City, Jeddah, Saudi Arabia, and identified predictors of non-adherence. Methods This retrospective cohort study included consecutive patients undergoing urine culture in the ED between September and December 2021. Two independent clinical pharmacists assessed appropriateness using the validated National Antimicrobial Prescribing Survey (NAPS) tool against the Ministry of National Guard Health Affairs (MNGHA) 2022 UTI guidelines across four domains: drug selection, dose, route, and duration. Two binary logistic regression models identified independent predictors of non-adherence and 30-day ED revisit. Results Of 346 patients (78.0% female), 184 (53.2%) had positive cultures and 216 (62.4%) received antibiotics. Overall, 153 (44.2%) had guideline-adherent management and 189 (54.6%) were non-adherent; among antibiotic-treated patients, only 31 (14.4%) received a guideline-adherent prescription. Leading non-adherence reasons were inappropriate drug selection (31.7%), overtreatment (29.6%), and resistance mismatch (13.8%). Positive culture (adjusted OR 1.89, p = 0.018) and UTI indication (adjusted OR 2.79, p < 0.001) independently predicted non-adherence. Positive-culture patients had higher 30-day ED revisit rates (26.6% vs. 14.8%, p = 0.008). Independent predictors of revisit were non-adherent prescribing (OR 2.20), pediatric age (OR 3.63), and prior antibiotic use (OR 2.91). Conclusions Antibiotic prescribing for UTIs in this tertiary ED demonstrated significant non-adherence to MNGHA guidelines, attributable primarily to inappropriate drug selection and overtreatment of culture-negative patients, and was independently associated with 30-day ED revisit. Electronic decision support, pharmacist-led culture follow-up, and local antibiogram updates are needed to improve prescribing quality. Addressing these gaps is an actionable priority for antimicrobial stewardship in resource-limited ED settings and is directly relevant to curbing antimicrobial resistance and improving patient safety. As a single-centre retrospective study restricted to culture-ordered patients, findings may not generalise to all ED UTI presentations.