Diagnostic Stewardship Intervention to Reduce Inappropriate Antibiotic Use for Urinary Tract Infections in Primary Care

A Randomized Controlled Trial of a Diagnostic Stewardship Intervention to Reduce Inappropriate Antibiotic Use for Urinary Tract Infections in Primary Care

Urine culture is the most common microbiological test in the outpatient setting in the United States. Unfortunately, contamination during collection is prevalent and undermines test accuracy, leading to incorrect diagnosis, unnecessary treatment, wasted laboratory resources, and inflated costs. Unnecessary antibiotic treatment increases the risk of developing antimicrobial resistance, one of the most serious threats to patients and public health. The goal of this clinical trial is to test whether a bilingual (English and Spanish) educational intervention, an animated video and pictorial flyer, can reduce urine culture contamination and associated inappropriate antibiotic use in adult patients visiting safety-net primary care clinics.

The main questions it aims to answer are:

1. Does providing patients with a bilingual educational intervention reduce urine culture contamination rates?
2. Does the intervention lead to fewer unnecessary urinary antibiotic prescriptions?
3. Does providing patients with a bilingual educational intervention reduce contaminated urinalyses? Researchers will compare patients randomized to receive the educational intervention (video and flyer) to those receiving usual care to see if the intervention improves urine collection accuracy and reduces inappropriate antibiotic use. Participants will watch a short, animated video with step-by-step instructions for proper midstream clean-catch urine (MSCC) collection, receive a pictorial flyer (with stills from the video) reinforcing the instructions, and provide a urine sample for culture. Hypothesis: patients who receive the educational intervention will have: lower urine culture contamination rates (primary outcome), fewer urinary antibiotic prescriptions (secondary outcome), and fewer contaminated urinalyses (secondary outcome). The objectives are to (1) develop educational tools: Create an animated video and pictorial flyer with step-by-step urine collection instructions for women and men, developed through an iterative, stakeholder-engaged process, (2) assess acceptability: Use mixed methods (quantitative surveys and qualitative interviews) to evaluate and refine the tools for usability and cultural/linguistic appropriateness, and (3) test effectiveness: Conduct a randomized controlled trial to assess the intervention's impact on urine contamination rates, antibiotic prescribing, and patient satisfaction.

Study Overview

• Status: Recruiting
• Conditions: Urinary Tract Infection(UTI); Antimicrobial Stewardship; Primary Care
• Intervention / Treatment: Behavioral: MSCC Educational Tool

Detailed Description

Background: Urinary tract infections (UTIs) account for more than 10 million ambulatory visits annually in the United States and are the third-leading cause of outpatient antibiotic prescriptions. Gram-negative urinary pathogens collected from outpatients across all regions of the United States now exhibit antimicrobial resistance levels that exceed thresholds recommended for empiric treatment of UTIs. Accurate urine cultures are essential for guiding antibiotic therapy. Midstream clean-catch (MSCC) urine collection is the gold standard for obtaining urine specimens, yet contamination rates in outpatient settings range from 46% to 55% in the recent studies. Contamination leads to incorrect diagnoses, unnecessary antibiotic use, increased resistance, and higher healthcare costs. Prior interventions aimed at reducing contamination have had mixed results and lacked stakeholder engagement and effective educational modalities.

Significance: This study addresses Goal 3 of the National Action Plan for Combating Antibiotic-Resistant Bacteria and CDC priorities by improving diagnostic accuracy and reducing inappropriate antibiotic use. Our approach empowers frontline staff and targets a neglected area of outpatient diagnostic stewardship. Urine culture contamination is common, wasteful, and harmful, particularly for pregnant patients who are routinely screened for bacteriuria. Contamination obscures true infection or leads to overtreatment, increasing risks for antimicrobial resistance, adverse drug reactions, and healthcare costs. Our intervention will improve patient care and reduce waste of laboratory resources.

Innovation and Impact: The proposed research is innovative because it places nurses and medical assistants at the forefront of antimicrobial stewardship in primary care. The investigators will develop a bilingual, multicultural educational intervention that includes an animated instructional video and a pictorial flyer. These materials will provide step-by-step guidance for proper MSCC urine collection and will be designed with input from patients, nurses, and medical assistants to ensure cultural competence and clarity for individuals with low literacy. This approach represents a departure from previous interventions, which lacked stakeholder engagement and failed to reduce contamination rates effectively. By incorporating stakeholder feedback and using engaging visual formats, the investigators aim to create an intervention that is acceptable, appropriate, and feasible for diverse patient populations.

Specific Aims: Aim 1: Iteratively develop a bilingual, multicultural educational intervention to reduce urine contamination, with stakeholder and expert input. The intervention will include an animated instructional video and a flyer with pictorial instructions that will provide step-by-step guidance to patients for collecting an MSCC urine sample. Aim 2: Perform a pilot study to assess and improve the intervention's acceptability, appropriateness, and feasibility using mixed methods. The investigators will use a sequential explanatory design that includes a quantitative survey and qualitative interviews with stakeholders (patients, nurses, and medical assistants). Aim 3: Test the effectiveness of the intervention at reducing urine culture contamination via a randomized controlled trial. The investigators hypothesize that patients who are randomized to receive the intervention versus usual care will have lower culture contamination rates (primary outcome), fewer urinary antibiotic prescriptions (secondary outcome), and fewer contaminated urinalyses (secondary outcome). Investigators will also study intervention fidelity, usability, and patient satisfaction using mixed methods research.

Methodology: The study will be conducted in two safety-net and one private primary care clinics. The investigators will use a randomized controlled trial with parallel groups to compare the intervention to usual care. Eligible participants will be adults aged 18 years or older who are asked to provide a urine sample for culture or urinalysis. Patients with indwelling urinary catheters or those unable to view the video or read the flyer in English or Spanish will be excluded. Randomization will occur at the patient level using a secure electronic system managed through REDCap. Participants assigned to the intervention group will view the animated video and flyer in their preferred language before urine collection. Men will receive materials tailored for men, and women will receive materials tailored for women. Participants in the control group will receive usual care without additional education. The primary outcome is the proportion of contaminated urine cultures, defined as mixed flora, growth of non-uropathogens, or growth of three or more uropathogens. Secondary outcomes include antibiotic prescribing within seven days of urine culture results and contamination of urinalyses, defined as more than ten squamous epithelial cells per microscopic field. The investigators will also assess implementation results through exit interviews and surveys. The sample size for the trial is 252 patients (126 per arm). Data will be collected from electronic medical records, patient surveys, and qualitative interviews. All data will be securely stored and de-identified for analysis.

Next Steps/Implementation: If the intervention proves effective, future work will focus on disseminating the educational tools to other settings, such as emergency departments and long-term care facilities. This project will provide a scalable, resource-efficient approach to improving diagnostic accuracy, reducing unnecessary antibiotic use, and advancing antimicrobial stewardship in outpatient care.

• Study Type: Interventional
• Enrollment (Estimated): 252
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Kiara Olmeda, MS; Phone Number: 7137983293; Email: kiara.olmeda@bcm.edu
• Study Contact Backup: Name: Azalia Mancera; Phone Number: 7137982910; Email: azalia.mancera@bcm.edu

Study Locations

• United States
  • Texas
    • Houston, Texas, United States, 77098
      • Recruiting
      • Baylor College of Medicine
      • Contact: Kiara Olmeda; Phone Number: 7137983293; Email: kiara.olmeda@bcm.edu

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Adults (≥18 years) undergoing urine culture as part of routine outpatient care
• Able to provide informed consent
• English- and or Spanish-speaking.

Exclusion Criteria:

• Presence of a urinary catheter
• Inability to read and sign the informed consent
• Unable to follow study procedures (due to significant visual, auditory, physical or cognitive impairment).

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Diagnostic
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: MSCC Educational Tool; Participants receive a standardized educational tool prior to urine collection. This includes a short video and flyer in English or Spanish explaining proper midstream clean-catch technique. Materials are shown in the exam room before specimen collection.	Behavioral: MSCC Educational Tool; A brief educational intervention (video + flyer) designed to improve urine collection technique and reduce contamination. Delivered in the patient's preferred language (English or Spanish) immediately before urine collection.
No Intervention: Usual Care; Participants receive standard clinical care without additional educational materials. Urine collection follows routine clinic procedures.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Urine Culture Contamination	Presence of mixed flora, growth of non-uropathogens, or growth of three or more uropathogens in urine culture results.	Within 48 hours of specimen collection

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Contaminated Urinalysis Status	Urine specimen will be considered contaminated if laboratory analysis reports 10 or more epithelial cells per high-power field.	Within 24-48 hours of specimen collection
Antibiotic Use	Antibiotic prescriptions associated with urine culture results.	Within 7 days post-collection
Patient Understanding and Satisfaction	Exit interviews assessing comprehension of collection steps, intervention fidelity and usability, and satisfaction with instructions. This survey will be completed with patients who received the intervention.	Immediately post-collection and after clinic visit.

Collaborators and Investigators

• Sponsor: Baylor College of Medicine
• Collaborators: Washington University School of Medicine
• Investigators: Principal Investigator: Larissa Grigoryan, MD, PhD, Baylor College of Medicine

Publications and helpful links

General Publications

• Bekeris LG, Jones BA, Walsh MK, Wagar EA. Urine culture contamination: a College of American Pathologists Q-Probes study of 127 laboratories. Arch Pathol Lab Med. 2008 Jun;132(6):913-7. doi: 10.5858/2008-132-913-UCCACO.
• Goebel MC, Trautner BW, Grigoryan L. The Five Ds of Outpatient Antibiotic Stewardship for Urinary Tract Infections. Clin Microbiol Rev. 2021 Dec 15;34(4):e0000320. doi: 10.1128/CMR.00003-20. Epub 2021 Aug 25.
• Reekie D. Ending the misery of child dental decay. Br Dent J. 1999 Aug 28;187(4):174-6. doi: 10.1038/sj.bdj.4800234.
• Gupta K, Grigoryan L, Trautner B. Urinary Tract Infection. Ann Intern Med. 2017 Oct 3;167(7):ITC49-ITC64. doi: 10.7326/AITC201710030.

Study record dates

Study Major Dates

• Study Start (Actual): January 22, 2026
• Primary Completion (Estimated): September 1, 2026
• Study Completion (Estimated): May 31, 2028

Study Registration Dates

• First Submitted: November 19, 2025
• First Submitted That Met QC Criteria: November 19, 2025
• First Posted (Actual): November 24, 2025

Study Record Updates

• Last Update Posted (Actual): February 13, 2026
• Last Update Submitted That Met QC Criteria: February 11, 2026
• Last Verified: February 1, 2026

More Information

Terms related to this study

• Keywords: Primary Care; Randomized Controlled Trial; Urinary Tract Infection; UTI; Antibiotic Resistance; Diagnostic Stewardship; Antimicrobial Stewardship; Inappropriate Antibiotic Use
• Additional Relevant MeSH Terms: Urogenital Diseases; Male Urogenital Diseases; Urologic Diseases; Female Urogenital Diseases; Female Urogenital Diseases and Pregnancy Complications; Infections; Urinary Tract Infections
• Other Study ID Numbers: H-53559; R01HS029489 (U.S. AHRQ Grant/Contract)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: Individual participant data will not be shared because participants did not provide consent for data sharing beyond the scope of this study, and sharing could compromise confidentiality despite de-identification efforts.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No