Strategies to uphold standards and tailor approaches for implementing national UTI guidelines: sustain-UTI

The National Institute of Diabetes and Digestive and Kidney Diseases awarded $912,876 to Seattle Children's Hospital (doing business as Seattle Children's Research Institute) on May 20, 2026, under the Diabetes, Digestive, and Kidney Diseases Extramural Research program (CFDA 93.847) to conduct a hybrid effectiveness-implementation trial testing sustainability strategies for evidence-based practice adherence in pediatric urinary tract infection management across 40 hospitals.

The trial, titled SUSTAIN-UTI (Strategies to Uphold Standards and Tailor Approaches for Implementing National UTI Guidelines), addresses the problem that clinician adherence to established evidence-based practices for UTI evaluation and management remains poor and highly variable despite guideline availability. Implementation efforts typically achieve only 6–10% improvements in adherence, with gains decaying to baseline within 12–18 months after support ends. Sustainability challenges are greatest in hospitals without specialized pediatric infrastructure, where low case volumes, limited pediatric expertise, and difficulty integrating pediatric-specific decision support tools hinder long-term adherence.

The research will test two strategies guided by the Dynamic Sustainability Framework. Hospitals achieving implementation benchmarks will be randomized to receive either audit and feedback alone (addressing monitoring barriers) or audit and feedback plus facilitated adaptation (addressing electronic health record integration and local context barriers). The trial will evaluate sustained adherence to core UTI evidence-based practices at 24 months post-implementation and will examine mechanisms of sustainability through habit formation at the clinician level and routinization at the organizational level.

Performance occurs in Seattle, Washington, with a period of performance from May 20, 2026, through January 31, 2031. The University of Washington serves as a sub-recipient under site-PIs Paul Fishman, PhD (economist) and KC Gary Chan, PhD (biostatistician), providing statistical design and economic cost-effectiveness analysis for the randomized controlled trial.

Abstract

Urinary tract infections (UTIS) affect 8% of children before age 18 and are a leading cause of renal scarring, which increases chronic kidney disease. Despite established evidence-based practices (EBPS) for UTI evaluation and management, clinician adherence remains poor and highly variable. While implementation efforts typically achieve 6-10% improvements in EBP adherence, these gains often decay to baseline levels within 12-18 months after support ends. Sustainability challenges are greatest in hospitals without specialized pediatric infrastructure, where low case volumes, limited pediatric expertise, and difficulty integrating pediatric-specific decision support tools hinder long-term adherence. The american academy of pediatrics (AAP) will publish updated UTI guidelines in 2026, providing a timely opportunity to test sustainability strategies. Guided by the dynamic sustainability framework, we will conduct a hybrid type III effectiveness-implementation trial with 40 hospitals stratified by hospital type. After implementation via the AAP infrastructure, hospitals achieving implementation benchmarks will be randomized to: (1) audit and feedback (providing performance data to address monitoring barriers) or (2) audit and feedback plus facilitated adaptation (addressing EHR integration and local context barriers through targeted modifications). Aim 1 evaluates the comparative effectiveness of strategies for sustaining EBP adherence over 24 months post-implementation. Our primary outcome is sustained adherence to ≥3 of 4 core UTI evidence-based practices at 24 months. Secondary outcomes include adherence patterns, clinical outcomes, and sustainability trajectories. Aim 2 uses mixed methods to test mechanisms - habit formation (clinician-level automaticity) and routinization (organization-level integration) - and assesses how absorptive capacity (the ability to acquire, assimilate, adapt, and integrate knowledge) moderates these pathways. Aim 3 conducts a pragmatic economic evaluation and develops a decision support tool to guide sustainability investments by hospital context. A sustained 8-10% improvement in EBP adherence could prevent 120-150 cases of renal scarring per 10,000 UTI cases, potentially reducing lifetime hypertension and chronic kidney disease. This research fills critical implementation science gaps and supports niddk priorities by generating actionable strategies to sustain pediatric kidney health improvements across hospital settings.