2026 Eastern States Conference

A Quality Improvement Project: Effect of Pharmacist Intervention on Inappropriate Cephalosporin Prescribing for Enterococcal Urinary Tract Infections (UTIs) in the Outpatient Setting 
Strawser B, PharmD; Lombardi N, PharmD; Logsdon J, PharmD
Background
Cephalosporins are frequently prescribed empirically for outpatient urinary tract infections (UTIs); however, enterococcal species are intrinsically resistant, making continued therapy inappropriate once urine culture speciation is available. Prior internal monitoring identified persistent continuation of cephalosporins for enterococcal UTIs despite existing education and decision support, indicating a gap in outpatient antimicrobial stewardship processes.
Local Problem
A subset of adult outpatients continued to receive ineffective cephalosporin therapy after urine cultures identified enterococcus species, representing inappropriate antibiotic use and a target for process improvement.
Methods
This quality improvement initiative evaluated a pharmacist-driven prospective audit and feedback intervention embedded within existing outpatient antimicrobial stewardship workflows. A Best Practice Advisory identified adult outpatients prescribed a cephalosporin with urine cultures positive for enterococcus species between September 2025 and March 2026. Pharmacists reviewed eligible cases and communicated antibiotic optimization recommendations to prescribing providers as appropriate. Outcomes were assessed using retrospective electronic health record review comparing patients who received pharmacist intervention with contemporaneous controls managed under standard workflows. Adults ≥18 with an active cephalosporin order within 7 days were included; inpatient cases or polymicrobial UTIs were excluded. The primary outcome was continuation of inappropriate cephalosporin therapy after culture speciation. Secondary outcomes included time to antibiotic change and 30‑day UTI-related healthcare utilization (ambulatory visits, emergency department visits, and inpatient admissions).
Results
Of 348 alerts generated, 146 patients met inclusion criteria (74 control; 72 intervention). Continuation of inappropriate antibiotic therapy occurred in 24.3% of control patients compared with 2.8% of patients receiving pharmacist intervention (p<0.001). Mean time to antibiotic change was 27.1 hours in the control group and 21.1 hours in the intervention group (p=0.17). UTI-related follow-up occurred in 16.2% of control patients and 12.5% of intervention patients, with fewer emergency department visits and hospital admissions observed in the intervention group.
Conclusions
Integration of pharmacist-led prospective audit and feedback into outpatient workflows significantly reduced inappropriate cephalosporin use for enterococcal UTIs. These findings demonstrate the effectiveness of leveraging existing stewardship infrastructure to improve prescribing practices and support ongoing local process improvement.
Self-Assessment Question:
A urine culture for an outpatient with a UTI grows Enterococcus species while the patient is receiving empiric cephalosporin therapy. What is the most appropriate next step?
A. Continue the cephalosporin since the patient is already improving
B. Discontinue the cephalosporin and switch to an antibiotic active against Enterococcus
C. Extend the duration of cephalosporin therapy to ensure eradication
D. Wait for repeat cultures before making any antibiotic changes