Introduction: Given the major threat of antimicrobial resistance, antibiotic stewardship interventions such as the publication of facility-specific guidelines (FSGs) for common infectious syndromes are required by accrediting organizations in attempt to combat resistance and improve patient outcomes. Personalized prescribing feedback with peer-comparison (PC) can increase adherence to society guidelines and reduce broad-spectrum antibiotic use (Buehrle, 2020; Clegg, 2019; Gerber, 2013; Meeker, 2016). The ED is Wright Patterson Medical Center’s (WPMC) highest volume prescriber of antibiotics for urinary tract and skin and soft-tissue infections, and overall adherence to FSGs for management of urinary tract infection (UTI) is historically low despite routine education and accessibility to electronic versions of FSGs. Our project aims to assess the effects of monthly PC report cards on ED adherence to FSGs for the treatment of UTI and skin and soft-tissue infections (SSTI) with a goal of improving UTI guideline adherence. Methods: A retrospective chart review was conducted from July 2023 through April 2024 regarding antibiotics prescribed by 20 clinicians in the ED for the applicable ICD-10 codes (using M2-Military health System Management and Reporting Tool) of UTI, SSTI, CAP, and sinusitis. A poster including the FSGs for UTI, SSTI, CAP, and sinusitis was displayed in the ED at the end of September 2023 after a UTI and CAP management briefing in February 2023. Monthly de-anonymized PC report cards of UTI FSG adherence were provided to the ED starting in January 2024 and SSTI encounters were added to the report in the following month. The report cards with specific feedback were sent to the ED ASP liaisons via email monthly. Patient demographics, FSG adherence scores (0.25 point per encounter for each correct criteria: diagnosis, antibiotic choice, antibiotic dose, antibiotic duration), UTI antibiogram, and syndrome resolution within two weeks were analyzed. Descriptive statistics were performed using Microsoft Excel version 2308. Bayesian analysis was performed with “R” version 4.0.3. Results: Encounters for 568 ED visits (295 UTI; 173 SSTI; 100 CAP) were reviewed. Median age of patients was 54 years (IQR 33-65 years) and 68% were female (387/568). Respective median FSG adherence scores increased for UTI and SSTI from 0.25 (IQR 0.25-0.75) and 0.75 (IQR 0.25-0.75) to 1.0 (IQR 0.25-1.0) and 0.75 (IQR 0.25-0.75) after PC. Before PC, cephalosporins were prescribed for 63% of UTIs (104/165); after PC the most prescribed antibiotics were nitrofurantoin (51%) and trimethoprim-sulfamethoxazole (17%). PC was more effective in improving guideline adherence scores for UTI versus the FSG poster display (0.43, CI 0.13-0.72 vs 0.24, CI -0.05-0.53). Each score-point improvement reduced the estimated days of antibiotic therapy (DOT) for UTI (2 days, p<0.01) and SSTI (5 days, p<0.01) without reducing therapeutic efficacy. PC did not affect DOT or therapeutic efficacy for the control syndrome (CAP). Conclusions: ED clinicians significantly increased their adherence to guideline-directed management of UTIs when publicly compared amongst their peers, significantly reducing both the spectrum of prescribed antibiotics and DOT without producing negative clinical outcomes; increasing the availability of facility-specific guidelines did not similarly increase guideline adherence.