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A qualitative analysis of diagnostic testing, antibiotic selection, and quality improvement interventions for uncomplicated urinary tract infections.

ABSTRACT: BACKGROUND:Uncomplicated urinary tract infections (UTIs) can often be diagnosed based solely on symptoms and should be treated with a short course of narrow spectrum antibiotics. However, clinicians often order urine analyses and prescribe long courses of broad spectrum antibiotics. OBJECTIVE:The objectives of our study are: 1) Understand how primary care providers and residents clinically approach UTIs and 2) to understand specific opportunities, based on provider type, to target future antibiotic stewardship interventions. DESIGN AND PARTICIPANTS:We conducted semi-structured qualitative interviews of community primary care providers (n = 15) and internal medicine residents (n = 15) in St. Louis, Missouri from 2018-2019. A 5-point Likert scale was used to evaluate participant preferences for possible interventions. Interviews were transcribed, de-identified, and coded by two independent researchers using a combination inductive and deductive approach. KEY RESULTS:Several common themes emerged. Both providers and residents ordered urine tests to "confirm" presence of urinary tract infections. Antibiotic prescription decisions were often based on historical practice and anecdotal experience rather than local susceptibility data or clinical practice guidelines. Community providers were more comfortable treating patients over the phone than residents and tended to prescribe longer courses of antibiotics. Both community providers and residents voiced frustrations with guidelines being difficult to easily incorporate due to length and extraneous information. Preferences for receiving and incorporating guidelines into practice varied. Both groups felt benchmarking would improve prescribing practices but had reservations about implementation. Community providers preferred pragmatic clinical decision support systems and nurse triage algorithms. Residents preferred order sets. CONCLUSIONS:Significant opportunities exist to optimize urinary tract infection management among residents and community providers. Multifaceted interventions that include provider education, synthesis of guidelines, and pragmatic clinical decision support systems are needed to improve antibiotic prescribing and diagnostic testing; optimal interventions to improve UTI management may vary based on provider training level.

SUBMITTER: Pinkerton M

PROVIDER: S-EPMC7467288 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

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A qualitative analysis of diagnostic testing, antibiotic selection, and quality improvement interventions for uncomplicated urinary tract infections.

Pinkerton Mark M Bongu Jahnavi J James Aimee A Lowder Jerry J Durkin Michael M

PloS one 20200902 9

<h4>Background</h4>Uncomplicated urinary tract infections (UTIs) can often be diagnosed based solely on symptoms and should be treated with a short course of narrow spectrum antibiotics. However, clinicians often order urine analyses and prescribe long courses of broad spectrum antibiotics.<h4>Objective</h4>The objectives of our study are: 1) Understand how primary care providers and residents clinically approach UTIs and 2) to understand specific opportunities, based on provider type, to target ...[more]

PMID: 32877460

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Project description:BackgroundMost diagnostic tests for acute uncomplicated urinary tract infections (UTIs) have been previously studied in so-called single-test evaluations. In practice, however, clinicians use more than one test in the diagnostic work-up. Since test results carry overlapping information, results from single-test studies may be confounded. The primary objective of the Amsterdam Cystitis/Urinary Tract Infection Study (ACUTIS) is to determine the (additional) diagnostic value of relevant tests from patient history and laboratory investigations, taking into account their mutual dependencies. Consequently, after suitable validation, an easy to use, multivariable diagnostic rule (clinical index) will be derived.MethodsWomen who contact their GP with painful and/or frequent micturition undergo a series of possibly relevant tests, consisting of patient history questions and laboratory investigations. Using urine culture as the reference standard, two multivariable models (diagnostic indices) will be generated: a model which assumes that patients attend the GP surgery and a model based on telephone contact only. Models will be made more robust using the bootstrap. Discrimination will be visualized in high resolution histograms of the posterior UTI probabilities and summarized as 5th, 10th, 25th 50th, 75th, 90th, and 95th centiles of these, Brier score and the area under the receiver operating characteristics curve (ROC) with 95% confidence intervals. Using the regression coefficients of the independent diagnostic indicators, a diagnostic rule will be derived, consisting of an efficient set of tests and their diagnostic values. The course of the presenting complaints is studied using 7-day patient diaries. To learn more about the natural history of UTIs, patients will be offered the opportunity to postpone the use of antibiotics.DiscussionWe expect that our diagnostic rule will allow efficient diagnosis of UTIs, necessitating the collection of diagnostic indicators with proven added value. GPs may use the rule (preferably after suitable validation) to estimate UTI probabilities for women with different combinations of test results. Finally, in a subcohort, an attempt is made to identify which indicators (including antibiotic treatment) are useful to prognosticate recovery from painful and/or frequent micturition.

Project description:Uncomplicated urinary tract infections (UTI) are common in primary care. Whilst primary care physicians are called to be antimicrobial stewards, there is limited primary care antibiotic resistance surveillance and physician antibiotic prescription data available in southern Chinese primary care. The study aimed to investigate the antibiotic resistance rate and antibiotic prescription patterns in female patients with uncomplicated UTI. Factors associated with antibiotic resistance and prescription was explored. A prospective cohort study was conducted in 12 primary care group clinics in Hong Kong of patients presenting with symptoms of uncomplicated UTI from January 2012 to December 2013. Patients' characteristics such as age, comorbidity, presenting symptoms and prior antibiotic use were recorded by physicians, as well as any empirical antibiotic prescription given at presentation. Urine samples were collected to test for antibiotic resistance of uropathogens. Univariate analysis was conducted to identify factors associated with antibiotic resistance and prescription. A total of 298 patients were included in the study. E. coli was detected in 107 (76%) out of the 141 positive urine samples. Antibiotic resistance rates of E. coli isolates for ampicillin, co-trimoxazole, ciprofloxacin, amoxicillin and nitrofurantoin were 59.8%, 31.8%, 23.4%, 1.9% and 0.9% respectively. E. coli isolates were sensitive to nitrofurantoin (98.1%) followed by amoxicillin (78.5%). The overall physician antibiotic prescription rate was 82.2%. Amoxicillin (39.6%) and nitrofurantoin (28.6%) were the most common prescribed antibiotics. Meanwhile, whilst physicians in public primary care prescribed more amoxicillin (OR: 2.84, 95% CI: 1.67 to 4.85, P<0.001) and nitrofurantoin (OR: 2.01, 95% CI: 1.14 to 3.55, P = 0.015), physicians in private clinics prescribed more cefuroxime and ciprofloxacin (P<0.05). Matching of antibiotic prescription and antibiotic sensitivity of E. coli isolates occurred in public than private primary care prescriptions (OR: 6.72, 95% CI: 2.07 to 21.80 P = 0.001) and for other uropathogens (OR: 6.19, 95% CI: 1.04 to 36.78 P = 0.034). Mismatching differences of antibiotic prescription and resistance were not evident. In conclusion, nitrofurantoin and amoxicillin should be used as first line antibiotic treatment for uncomplicated UTI. There were significant differences in antibiotic prescription patterns between public and private primary care. Public primary care practitioners were more likely to prescribe first line antibiotic treatment which match antibiotic sensitivity of E. coli isolates and other uropathogens. Further exploration of physician prescribing behaviour and educational interventions, particularly in private primary care may helpful. Meanwhile, development and dissemination of guidelines for primary care management of uncomplicated UTI as well as continued surveillance of antibiotic resistance and physician antibiotic prescription is recommended.

Project description:INTRODUCTION:Urinary tract infections (UTI) are a common indication for antibiotic use in the emergency department (ED). With antibiotic resistance on the rise, it is essential that antibiotics be prescribed appropriately for UTIs. Our objective was to evaluate the appropriateness of antibiotic prescriptions by ED providers for uncomplicated cystitis and pyelonephritis. METHODS:We conducted a retrospective study of females ages 2-50 years seen in an academic ED from January 2017 to April 2018 diagnosed with UTI. We assessed the appropriateness of discharge antibiotic prescriptions, as determined by adherence to clinical practice guidelines, best evidence for the particular indication (cystitis vs pyelonephritis for children and adults), and the local antibiogram. RESULTS:A total of 421 patients were included in this study. Of these, 60 children and 198 adults were diagnosed with cystitis, and 47 children and 116 adults were diagnosed with pyelonephritis. Treatment in the absence of true infection was common, with culture-confirmed UTI occurring in only 17/50 (34%) of children and 60/129 (47%) of adults diagnosed with cystitis, and 23/40 (58%) of children and 58/87 (67%) of adults diagnosed with pyelonephritis, among patients who had urine cultures. The type of antibiotic prescribed was appropriate in 53/60 (88%) of children and 135/198 (68%) of adults with cystitis, and 38/47 (81%) of children and 53/116 (46%) of adults with pyelonephritis. The most common inappropriate antibiotic types were beta-lactams in adults (n = 92), nitrofurantoin for pyelonephritis (n = 16), and amoxicillin (n = 15). Dosing and duration errors were also common, occurring in 122/279 (44%) of prescriptions of an appropriate antibiotic type. The frequency of errors in the type of antibiotic prescribed was similar among provider types (attending physician, resident physician, and advanced practice clinician; p = 0.926). CONCLUSION:This study reveals room for improvement in antibiotic prescription practices across provider cohorts in the ED for the management of uncomplicated cystitis and pyelonephritis in females.

Project description:BackgroundAmid growing antimicrobial resistance, there is an increasing focus on antibiotic stewardship efforts to reduce inappropriate antibiotic prescribing. In this context, novel approaches for treating infections without antibiotics are being explored. One such strategy is the use of non-steroidal anti-inflammatory drugs (NSAIDs) for uncomplicated urinary tract infections (UTIs). Therefore, we conducted a systematic review of randomized controlled trials to evaluate the rates of symptom resolution and infectious complications in adult women with uncomplicated UTIs treated with antibiotics versus NSAIDs.MethodsWe systematically searched PubMed, CINHAL, Scopus, Web of Science Core Collection, EMBASE, and ClinicalTrials.gov from inception until January 13, 2020, for randomized controlled trials comparing NSAIDs with antibiotics for treatment of uncomplicated UTIs in adult women. Studies comparing symptom resolution between groups were eligible. Two authors screened all studies independently and in duplicate; data were abstracted using a standardized template. Risk of bias was assessed using the Cochrane Collaboration tool.ResultsFive randomized trials that included 1309 women with uncomplicated UTI met inclusion criteria. Three studies (1130 patients) favored antibiotic therapy in terms of symptom resolution. Two studies (179 patients) found no difference between NSAIDs and antibiotics in terms of symptom resolution. Three studies reported rates of pyelonephritis, two of which found higher rates in patients treated with NSAIDs versus antibiotics. Between two studies that reported this outcome (747 patients), patients randomized to NSAIDs received fewer antibiotic prescriptions compared with those in the antibiotics group. Three studies were at low risk of bias, one had an unclear risk of bias, and one was at high risk of bias.DiscussionFor the outcomes of symptom resolution and complications in adult women with UTI, evidence favors antibiotics over NSAIDs.ProsperoCRD42018114133.

Project description:ObjectivesTo determine the feasibility of conducting a randomised trial of the effectiveness of cranberry extract in reducing antibiotic use by women with symptoms of acute, uncomplicated urinary tract infection (UTI).DesignOpen-label feasibility randomised parallel group trial.SettingFour general practices in Oxfordshire.ParticipantsWomen aged 18 years and above presenting to general practice with symptoms of acute, uncomplicated UTI.InterventionsWomen were randomly assigned using Research Electronic Data Capture in a 1:1:1 ratio to: (1) immediate antibiotics alone (n=15); (2) immediate antibiotics and immediate cranberry capsules for up to 7 days (n=15); or (3) immediate cranberry capsules and delayed antibiotics for self-initiation in case of non-improvement or worsening of symptoms (n=16).Primary and secondary outcome measuresThe primary outcome measures were: rate of recruitment of participants; numbers lost to follow-up; proportion of electronic diaries completed by participants; and acceptability of the intervention and study procedures to participants and recruiters. Secondary outcomes included an exploration of differences in symptom burden and antibiotic use between groups.ResultsFour general practitioner practices (100%) were opened and recruited participants between 1 July and 2 December 2019, with nine study participants recruited per month on average. 68.7% (46/67) of eligible participants were randomised (target 45) with a mean age of 48.4 years (SD 19.9, range 18-81). 89.1% (41/46) of diaries contained some participant entered data and 69.6% (32/46) were fully complete. Three participants (6.5%) were lost to follow-up and two (4.4%) withdrew. Of women randomly assigned to take antibiotics alone (controls), one-third of respondents reported consuming cranberry products (33.3%, 4/12). There were no serious adverse events.ConclusionsIt appears feasible to conduct a randomised trial of the use of cranberry extract in the treatment of acute, uncomplicated UTI in general practice.Trial registration numberISRCTN Registry (ID: 10399299).

Project description:BackgroundConsultations in primary care for symptoms of urinary tract infections (UTIs) are common and patients are frequently treated with antibiotics. Given increasing antimicrobial resistance, there has been interest in non-antibiotic treatment options for common infections. One such option is the use of cranberry extract to treat symptoms attributable to UTIs.MethodsA target of 45 women consulting in primary care, with symptoms suggestive of an uncomplicated UTI for whom the practitioner would normally prescribe antibiotics, will be randomised to receive one of three treatment approaches: (1) immediate prescription for antibiotics; (2) immediate prescription for antibiotics plus a 7-day course of cranberry capsules and (3) cranberry capsules plus a delayed prescription for antibiotics to be used in case their symptoms do not get better, or get worse. Follow-up will be by daily rating of symptoms and recording of treatments used for 2 weeks in an online symptom diary. Interviews will be conducted with around 10-15 study participants, as well as with around 10-15 women who have experienced a UTI but have not been approached to take part in the study. Both groups will be asked about their experience of having a UTI, their thoughts on non-antibiotic treatments for UTIs and their thoughts on, or experience of, the feasibility trial. The primary objective is to assess the feasibility of undertaking a full trial in primary care of the effectiveness of cranberry extract to reduce antibiotic use for symptoms of acute uncomplicated UTI. The secondary objective is to conduct a preliminary assessment of the extent to which cranberry might reduce antibiotic use and symptom burden.DiscussionThis feasibility study with embedded interviews will inform the planning and sample size calculation of an adequately powered trial to definitively determine whether cranberry helps to alleviate the symptoms of acute uncomplicated UTIs in women and whether it can safely reduce antibiotic use.Trial registrationISRCTN registry, ID: 10399299. Registered on 24 January 2019.

Dataset Information

A qualitative analysis of diagnostic testing, antibiotic selection, and quality improvement interventions for uncomplicated urinary tract infections.

Publications

A qualitative analysis of diagnostic testing, antibiotic selection, and quality improvement interventions for uncomplicated urinary tract infections.

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