Improving Antibiotic Prescribing for Urinary Tract Infections through Prospective Audit and Feedback: A Before–After Antimicrobial Stewardship Study in a Tertiary Care Hospital

Abstract Background Urinary tract infections (UTIs) are a leading indication for antimicrobial therapy and a common source of inappropriate prescribing. Prospective audit and feedback (PAF) is recommended by international stewardship guidelines, but syndrome-specific data integrating diagnostic and antimicrobial stewardship from resource-limited settings are scarce. Methods We conducted a prospective, quasi-experimental, three-phase (pre-intervention, intervention, post-intervention) study in adult inpatients with suspected or confirmed UTI at a tertiary care teaching hospital (100 patients/phase). During the intervention phase, a multidisciplinary team performed structured PAF within 24–48 hours of antibiotic initiation. Diagnostic stewardship, prescribing appropriateness, antimicrobial utilization (DOT, LOT, DDD), and clinical outcomes were compared across phases. Results Documentation of syndromic diagnosis (78% to 100%), pre-antibiotic urine culture (74% to 95%), and blood culture collection (16% to 48%) improved significantly (all p < 0.05). Appropriate antimicrobial use increased from 41% to 91% and culture-guided de-escalation from 6% to 27–28% (p < 0.001). Renal dose adjustment and compliance with institutional guidelines also improved significantly. Overall antimicrobial exposure (DOT) remained stable, while LOT and DDD declined modestly. Fever defervescence occurred earlier post-intervention (p = 0.004), while hospital stay, ICU stay, and mortality were unchanged. A greater proportion of catheter-associated UTIs and comorbidities were noted in later phases. Conclusions A syndrome-specific PAF intervention integrated with diagnostic stewardship produced sustained improvements in antimicrobial appropriateness and diagnostic practices without compromising clinical safety, supporting its feasibility in resource-limited hospital settings.