Antibiotic Prescribing for Urinary Tract Infections
Abstract and Introduction
Objectives Urinary tract infections (UTIs) are one of the most common infections encountered in ambulatory care and inpatient settings. Although these infections are common, not all patients are prescribed an appropriate antibiotic or duration of therapy. The primary objective of this analysis was to evaluate the appropriateness of antibiotic selection and duration of therapy for patients in an adult internal medicine clinic diagnosed as having a UTI.
Methods We conducted a retrospective chart review (July 1, 2012–June 30, 2013) of adult patients in an internal medicine clinic who were diagnosed as having a UTI. Pediatric and pregnant patients were excluded from the analysis. Data pertaining to the classification of UTI, antibiotic regimen, urine culture, and renal function were collected. All of the data were analyzed to determine whether the prescribing habits at the internal medicine clinic aligned with Infectious Diseases Society of America (IDSA) guidelines for antibiotic selection and duration of therapy for acute uncomplicated cystitis, complicated cystitis, catheter-associated UTI, and pyelonephritis.
Results There were 269 records available for the analysis, with the majority of the cases being uncomplicated and complicated UTIs. Of 128 cases of patients with uncomplicated UTIs and 116 cases of patients with complicated UTIs, 64.1% and 42.2%, respectively, were prescribed appropriate first- or second-line therapy, which aligned with the recommendations of the IDSA. Regarding the individual components of the UTI treatment regimen, antibiotic selection had the highest frequency of appropriateness, with 97.6% of uncomplicated UTI cases and 90.5% of complicated UTI cases having been treated with a recommended antibiotic. In contrast, the treatment duration for uncomplicated and complicated UTIs had the lowest frequency of appropriateness, at 71.9% and 58.6%, respectively.
Conclusions Receiving an adequate antibiotic regimen for a UTI is important to prevent treatment failure and the emergence of resistant organisms. Overall, the studied antibiotic regimens prescribed for various UTIs diagnosed in the clinic did not align with the IDSA recommendations.
Urinary tract infections (UTIs) are one of the most common infections encountered in both inpatient and outpatient settings. These infections are classified as either complicated or uncomplicated based on contributing factors such as male sex, structural or anatomical abnormalities, kidney or bladder dysfunction, and/or catheter use. Although these infections are common, not all patients are prescribed an appropriate antibiotic or a duration of therapy to adequately treat the infection.
The Infectious Diseases Society of America (IDSA) provides guidelines that detail the recommended antibiotic regimens for UTIs (Table 1). These guidelines provide evidence-based recommendations for empiric treatment of complicated and uncomplicated cystitis, pyelonephritis, and catheter-associated UTIs. An additional guideline from IDSA is available for asymptomatic bacteriuria. The various guidelines provided by IDSA make recommendations for the choice of antibiotic, dose and frequency, and duration of therapy. Because IDSA advocates specific antibiotic regimens based on the available literature regarding treatment options, patients who do not receive an appropriate antibiotic regimen are at risk for treatment failure.
Previous reports in the literature have assessed the adherence of clinicians to the recommendations given by IDSA. Taur and Smith conducted a study to determine whether the antibiotic selection for a UTI in women was influenced by the IDSA guidelines. The most frequently prescribed antibiotics were sulfamethoxazole-trimethoprim (SMX-TMP), ciprofloxacin, and nitrofurantoin, which align with the first- and second-line therapies recommended by IDSA. Healthcare providers in hospitals were more likely than outpatient physicians to prescribe SMX-TMP (54.7% vs 27.6% of 1059 and 1280, respectively; P < 0.001). Outpatient providers were more likely than providers in hospital clinics to prescribe ciprofloxacin for an uncomplicated UTI (24.8% vs 18.1%; P = 0.038).
In addition to the findings of Taur and Smith, an assessment of adherence to the evidence-based guidelines for uncomplicated UTIs was studied at the Mayo Clinic Family Medicine Center in Scottsdale, Arizona. Of 68 patients analyzed, 38% were prescribed the recommended SMX-TMP and 53% were prescribed ciprofloxacin, which is not currently recommended as a first-line therapy by IDSA. IDSA also recommends that patients receiving SMX-TMP for an uncomplicated UTI should receive treatment for 3 days; however, antibiotic courses for >3 days were prescribed for 39% of the patients in this study. Likewise, Willems and colleagues assessed the frequency of urinary tract infections among healthy women and the appropriate use of antibiotics according to the Belgian guideline. Of 134 patients diagnosed as having an uncomplicated UTI, an appropriate antibiotic regimen was chosen in only 29.4% of the cases.
Furthermore, a study to determine antibiotic selection, initiation, and duration of therapy among patients in two Rhode Island nursing facilities was conducted by Rotjanapan and colleagues. Of 172 patients, 72% received inappropriate antibiotic therapy when compared with IDSA criteria. Forty-six percent of patients received inappropriate drug dosing based on creatinine clearance, and 67% received antibiotics for longer than the recommended duration.
The consequences of inappropriate UTI therapy include increased in vitro resistance of bacteria as well as negative ecological effects from the development of bacterial resistance to antimicrobial therapy. All of these effects ultimately reduce favorable patient outcomes and potentially increase the cost of health care. The primary objective of this study was to evaluate the appropriate selection and length of therapy for patients in an adult internal medicine clinic diagnosed as having a UTI.