Impact of a multimodal antimicrobial stewardship intervention on fluoroquinolone usage for antimicrobial prophylaxis before urologic procedures in a Veterans Affairs outpatient clinic

Objective: This study evaluated the impact of a multimodal antimicrobial stewardship intervention on fluoroquinolone (FQ) use for prophylaxis in outpatient urologic procedures. Methods: This single-center retrospective cohort study included patients from the South Texas Veterans Affairs (VA) outpatient urology clinic who underwent procedures between December 1, 2020, and February 29, 2024. Interventions included academic detailing, provider-specific FQ use reports, and prospective urine culture reviews with feedback. One pre-intervention cohort (PRE) and three post-intervention cohorts (POST2021, POST2022, POST2023) were analyzed. The primary outcome was FQ days of therapy (DOT); secondary outcomes included inappropriate prescriptions, post-operative complications, emergence of FQ resistance within 1 year, and Clostridioides difficile infection within 30 days of prophylaxis. Results: This analysis included data from 548 patients (150 PRE, 139 POST2021, 168 POST2022, 91 POST2023). Median age was similar across groups (p = 0.20), with over 90% male in each cohort (p = 0.07). Over one-third in each cohort received pre-operative oral antibiotics, 25% of which were FQs. More than 90% received pre-operative IV antibiotics, and over 50% received post-operative oral antibiotics. A significant reduction in FQ DOT/100 procedures was noted from pre- to post-intervention groups (98.6 PRE, 49.6 POST2021, 53.5 POST2022, 45.1 POST2023). No significant differences were observed in the secondary clinical outcomes. Conclusion: A multimodal stewardship initiative reduced FQ use before urologic procedures, mainly due to decreased IV use. Further efforts are needed to optimize pre-operative FQ use and address drivers of post-operative antibiotic prescribing.