ARE YOU TREATING UNCOMPLICATED UTIs CORRECTLY ?

I support this paper's conclusions and recommendations.

Main points.

This is for outpatients, or clinic patients, not inpatients, not for nosocomial infections.
It is scientific and evidence based in 2007 not to order urine culture and sensitivity for suspected uncomplicated UTIs, if people dispute you remember this article.
Three days is the duration of treatment not seven days not fourteen says- I have seen all these being done.
The medication is Bactrim DS for below the age of say 60 and single strength BID for older folks in my opinion . In renal insufficiency do not use Bactrim at all.

In sulfa allergic patients use Cipro.

Amoxicillin or Keflex is not the right choice as it kills too many other bacteria also which causes other problems, like vaginitis etc etc. Nitrofurnatoin may be.

But do not lose the focus, the treatment of choice is Bactrim for three days. For uncomplicated UTIs. You need a urine dipstck in all cases at least in this paper unless you know the patient from before and has had previous UTI. You can debate that point but do not lose the focus

The treatment is for three days not 10- 14 days.

It is perfectly kosher to order three days treatment any thing more is an over kill, and too expensive and is for no scientific reason. It is our job to highlight the right answer. Probably no one has seen the reference #1 given below

KK










ORIGINAL ARTICLE

Assessing Adherence to Evidence-Based Guidelines for the Diagnosis and Management of Uncomplicated Urinary Tract Infection
MICHAEL L. GROVER, DO; JESSE D. BRACAMONTE, DO; ANUP K. KANODIA, MD; MICHAEL J. BRYAN, MD; SEAN P. DONAHUE, DO; ANNE-MARIE WARNER, MD; FREDERICK D. EDWARDS, MD; AMY L. WEAVER, MS
From the Department of Family Medicine, Mayo Clinic College of Medicine, Scottsdale, Ariz (M.L.G., J.D.B., A.K.K., M.J.B., S.P.D., A.-M.W., F.D.E.); and Division of Biostatistics, Mayo Clinic College of Medicine, Rochester, Minn ( A.L.W.). Dr Kanodia is now with Osher Institute, Harvard Medical School, Boston, Mass. Dr Bryan is in private practice in Prescott, Ariz. Dr Donahue is now with the Stanford University, Stanford, Calif. Dr Warner is now with Maricopa Integrated Health Systems and Medpro Associates, Phoenix, Ariz.




Abstract


OBJECTIVE: To assess adherence to evidence-based guidelines for the diagnosis and management of uncomplicated urinary tract infection (UTI) in a family medicine residency clinic setting.

PATIENTS AND METHODS: We retrospectively reviewed the medical records of female patients seen in 2005 at the Mayo Clinic Family Medicine Center in Scottsdale, Ariz, who were identified by International Classification of Diseases, Ninth Revision code 599.0 (UTI). We assessed documentation rates, use of diagnostic studies, and antibiotic treatments. Antibiotic sensitivity patterns from outpatient urine culture and sensitivity analyses were determined.

RESULTS: Of 228 patients, 68 (30%) had uncomplicated UTI. Our physicians recorded essential history and examination findings for most patients. Documentation of the risk of sexually transmitted disease differed between residents and attending physicians and was affected by patient age. Urine dipstick and urine culture and sensitivity analyses were ordered in 57 (84%) and 52 (76%) patients, respectively. Eighty percent of patients with positive results on urine dipstick analyses also had urine culture and sensitivity analyses. Sulfamethoxazole-trimethoprim (SMX-TMP) was used as initial therapy in 26 patients (38%). Sixty-one percent of SMX-TMP and ciprofloxacin prescriptions were appropriately provided for 3 days. Escherichia coli was sensitive to SMX-TMP in 33 (94%) of 35 cultures. Treatment was not changed in any patient with an uncomplicated UTI because of results of urine culture and sensitivity analyses. Antibiotic sensitivity patterns for outpatients were significantly different from those for inpatients.

CONCLUSION: Only 30% of our patients had uncomplicated UTI, making their management within clinical guidelines appropriate. However, of those patients with uncomplicated UTI, less than 25% received empirical treatment as suggested. Urine culture and sensitivity analyses were performed frequently, even in patients who already had positive results on a urine dip-stick analysis. Although SMX-TMP is effective, it is underused. On the basis of these findings, we hope to provide interventions to increase SMX-TMP prescription, decrease use of urine culture and sensitivity analyses, and increase the frequency of 3-day antibiotic treatments at our institution.

Mayo Clin Proc. 2007;82(2):181-185


EMR=electronic medical record; SMX-TMP=sulfamethoxazole-trimethoprim; STD=sexually transmitted disease; UTI=urinary tract infection



--------------------------------------------------------------------------------

Urinary tract infection (UTI) is a common chief complaint at primary care offices, accounting for approximately 8.3 million physician visits per year. 1 Because UTI is a common illness, its diagnosis and treatment have important implications for patient health, development of antibiotic resistance, and health care costs. Several evidence-based guidelines and reviews have provided diagnostic and management strategies. 2-5 These guidelines argue against performance of urine culture and sensitivity analyses in patients with classic signs and symptoms of uncomplicated UTI. Furthermore, sulfamethoxazole-trimethoprim (SMX-TMP) for 3 days is advocated as the antibiotic of choice because of its low cost and efficacy.

With this information available, it would seem logical that physician practice would conform to published practice guidelines. However, the reality is that many physicians continue to practice largely independent of these recommendations. 6-11 One study in 1999 of more than 2100 physicians found great variability in UTI management. 6 Many physicians continued to obtain urine cultures. Nearly 30% did not use SMX-TMP as the first-line agent, and almost half of obstetrician-gynecologists used nitrofurantoin as their antibiotic of choice in nonpregnant, low-risk patients. Only about half of physicians treated patients with antibiotics for the recommended 3-day duration. In 2003, a study analyzing more than 10,000 insurance claims found that physicians generally did not use SMX-TMP as the first-line agent, and the duration of treatment was often much longer than the recommended 3 days. 7 Studies have shown that urologists appear to have the best adherence to guidelines. 9 Nonadherence can profoundly affect health care costs.10

We hypothesized that a similar gap between national guidelines and physician practice patterns existed at our primary care practice. Thus, we retrospectively reviewed medical records to evaluate our physicians' practices for diagnosing uncomplicated UTI in female patients. The objectives of this study were to determine (1) the frequency of appropriate documentation of patient histories and essential physical examination findings, (2) the frequency of urine culture and sensitivity analysis being used as a diagnostic tool, (3) the efficacy of SMX-TMP as empirical treatment in this population of patients, and (4) the frequency of short-course (3-day) antibiotic treatments.


PATIENTS AND METHODS


We selected a cohort of women who were patients of the Mayo Clinic Scottsdale Family Medicine Center in Arizona in 2005. Patients were identified by using the diagnosis of UTI (International Classification of Diseases, Ninth Revision code 599.0). We reviewed medical charts and evaluated the first visit of the year in which a UTI was diagnosed. The visit was included for further analysis if the patient was seen in the physician's office for evaluation of symptomatic complaints. Visits were not included for further analysis if patients were being seen at follow-up for a previous evaluation performed elsewhere, were managed by telephone contact, or had urine testing performed for screening or other asymptomatic purposes. Patients with complicated UTI, as defined by the Institute for Clinical Systems Improvement guidelines, 3 were excluded. Exclusion criteria included age younger than 18 years and older than 65 years, symptoms for more than 7 days, documented or reported fever (temperature ≥38.3°C), nausea or vomiting, concomitant symptoms or diagnosis of vaginitis, reported or reproduced flank pain, a history of 4 UTIs in the past 12 months, or failure of SMX-TMP treatment of a UTI in the preceding 4 weeks. Pregnant women, nursing home residents, and individuals with functional or anatomical abnormality (polycystic renal disease, nephrolithiasis, neurogenic bladder, diabetes mellitus, immunosuppression, indwelling Foley catheter, or recent urinary tract instrumentation) were not included in this study. Therefore, patients who were not excluded on the basis of these criteria were considered to have had an uncomplicated UTI (ie, no signs or symptoms of upper urinary tract disease or markers of medical complications).

Data Collection

History and Physical Examination. We recorded the presence or absence of documentation from our electronic medical record (EMR) regarding potential signs and symptoms of uncomplicated UTI (dysuria, frequency, urgency, and hematuria). We collected data on the exclusion of upper urinary tract disease (patient denied fever and flank pain and the absence of fever or flank tenderness on examination) and vaginitis (absence of vaginal discharge or irritability symptoms and sexually transmitted disease [STD] risks). Whether physicians used an available documentation tool within our EMR for recording UTI patient visits was assessed. We also determined whether care was provided by a resident or an attending physician.

Diagnostic Studies. We collected information about performance and results of urine dipstick analyses, microscopic urinalyses, and urine culture and sensitivity analyses.

Treatment. Data collection on treatment included the antimicrobial prescribed and duration of therapy.

Statistical Analyses

We developed a data collection sheet on which to record information from our medical chart review. Data from these sheets were entered into an Excel database and analyzed using the SAS software package (Version 8.2, SAS Institute Inc, Cary, NC).

We used descriptive statistics to present frequencies, percentages, means, SDs, and ranges. We used the 2-sided χ2 test and the Fisher exact test to compare documentation rates, test utilization, and treatments provided between groups (eg, did vs did not use EMR documentation tool, attending physicians vs residents). We determined the antibiotic sensitivity patterns of Escherichia coli bacteria to SMX-TMP based on available urine culture and sensitivity analyses. A 2-sided 1-sample binomial test was used to compare the observed urine culture sensitivities for patients with uncomplicated UTI in the outpatient setting with rates reported for inpatients. All calculated P values were 2-sided, and P<.05 was considered statistically significant. This study was approved by the Mayo Foundation Institutional Review Board.


RESULTS


We identified 332 female patients who had a UTI diagnosis recorded in 2005. Of these 332 patients, 104 were excluded because they did not have an office visit for evaluation of symptomatic complaints (ie, they had initial evaluations elsewhere, were managed by telephone contact, or had testing performed for screening or other asymptomatic reasons). Thus, 228 patients met inclusion criteria, and their initial UTI visits were evaluated for exclusion criteria to determine whether their infections were uncomplicated or complicated. Sixty-eight patients (30%) had uncomplicated UTI ( Figure 1). The remaining 160 patients (70%) were determined to have complicated UTI and were excluded from further analysis.

The reasons for exclusion are listed in Table 1. The most common reason for exclusion was patient age older than 65 years (106/160 patients [66%]). The mean (SD) age of the 68 patients with an uncomplicated UTI was 41.2 (14.7) years, with a median age of 44.5 years and an interquartile range of 28 to 54 years. Forty-six patients (68%) were seen by a resident and 22 (32%) by an attending physician.

Documentation of History and Physical Examination Findings

Our physicians recorded essential history and examination findings for most patients (Table 2). For instance, the presence or absence of dysuria was documented in 64 (94%) of the 68 medical records. However, absence of vaginal discharge or irritation and absence of STD risks were documented less often (51% and 24%, respectively).


FIGURE 1. Inclusion and exclusion criteria. UA=urinalysis; UTI=urinary tract infection.





Use of our EMR documentation tool improved documentation rates for some aspects of the UTI history. Documentation of absence of vaginal irritation increased from 41% in the 53 encounters in which this tool was not used to 87% in the 15 encounters in which this tool was used ( P=.003). Residents were more likely to use this tool than were attending physicians (28% vs 9%, respectively; P=.12).

Residents documented some of the history and physical examination findings more often than did attending physicians. Residents were more likely to document absence of STD risks (30% vs 9%; P=.07), absence of flank tenderness (87% vs 55%; P=.006), and presence of suprapubic tenderness (96% vs 73%; P=.01).

Documentation of STD risk was affected by patient age. In the 14 patients who were 25 years of age or younger, a history of STD risk was documented in 6 (43%). However, in the 54 patients older than 25 years, this information was documented only in 10 (19%). Although this appears to be a clinically important difference, it was not statistically significant ( P=.08), most likely because of the small number of young patients.

Diagnostic Testing

We analyzed the performance and results of urine dipstick analyses, microscopic urinalyses, and urine culture and sensitivity analyses. In 57 (84%) of 68 patients with uncomplicated UTI, urine dipstick tests were ordered. Of these 57 patients, 41 (72%) had positive results on dipstick analyses for either leukocyte esterase or nitrites. Of the patients with positive results on urine dipstick analyses, 8 (20%) also had formal microscopic urinalyses performed in our laboratory, and 33 (80%) also had a urine culture performed.

Of 68 patients with uncomplicated UTI, 52 (76%) had a culture ordered during their office visits. Thirty-eight (73%) of the 52 cultures grew pathogens; 10 cultures had mixed flora (ie, were contaminated), and 4 had no growth. Thirty-five of the 38 urine cultures that grew pathogens were positive for E coli (ie, 92% of positive cultures had E coli). Nearly all E coli bacteria in our patients with uncomplicated UTI were sensitive to SMX-TMP (33/35 [94% sensitive]). In these patients with uncomplicated UTI, no E coli resistance was found to nitrofurantoin, ciprofloxacin, or cephalexin. E coli was sensitive to ampicillin-amoxicillin in only 25 (71%) of the 35 cultures. No study patient with uncomplicated UTI had treatment changed because of bacterial resistance found on her urine culture.



TABLE 1. Reasons for Exclusion as a Function of Patient Age*
Exclusion criteria
-------------------------------------------------------------------------------------





TABLE 2. Documentation of UTI History and Physical Examination Findings in the 68 Patients With Uncomplicated UTI*
-------------------------------------------------------------------------------------


Antibiotic Treatment

All 68 patients received antibiotic treatment. Twenty-six patients (38%) were prescribed SMX-TMP, and 36 patients received ciprofloxacin (53%). The mean treatment duration was 3.5 days with SMX-TMP and 4.3 days with ciprofloxacin. Sixty-one percent of SMX-TMP and ciprofloxacin prescriptions (38/62) were appropriately provided for 3 days. A similar proportion of attending physicians and residents prescribed the recommended 3-day course of antibiotics (13/22 [59%] and 26/46 [57%], respectively). There was a statistically significant difference between residents and attending physicians in the type of antibiotic used. Attending physicians prescribed ciprofloxacin for most of the patients they treated (14 [64%]) of the 22 prescriptions they wrote), whereas residents prescribed either SMZ-TMP or ciprofloxacin with equal frequency (22 [48%] of the prescriptions for each antibiotic) ( P=.01).

Comparing Outpatient to Inpatient Urine Culture and Sensitivity Patterns

We determined that urine culture sensitivity patterns for uncomplicated UTI in outpatients were significantly different from those of inpatients. E coli bacteria were sensitive to SMX-TMP in 94% of outpatient cultures, whereas they were sensitive in only 76% of inpatient cultures ( P=.01). E coli was also significantly more sensitive to other antibiotics for outpatient cultures (ciprofloxacin, 100% vs 81%; P=.001; cephalexin, 100% vs 90%; P=.05). Ampicillin-amoxicillin was a poor treatment choice for E coli UTI because of high rates of resistance. Sensitivity patterns between outpatients and inpatients were not significantly different (71% vs 59%; P=.18).


DISCUSSION


Evaluating and treating patients with UTI symptoms is a common situation for primary care physicians. National guidelines have advocated identification of patients with uncomplicated UTI through risk stratification and empirical therapy with SMX-TMP if resistance rates to E coli are low.2,3 Only 30% of our patients had uncomplicated UTI, making their management within clinical guidelines appropriate. However, of those patients with uncomplicated UTI, less than 25% received empirical treatment as suggested. Our patient population is older, with many having complicating medical problems. Most patients in our practice require office-based evaluation and confirmation of effectiveness of the chosen antibiotic based on urine culture and sensitivity results.

For patients with uncomplicated UTI, our documentation of essential history and physical examination findings appeared adequate. For example, the documentation rates of dysuria and frequency symptoms were good. Residents performed slightly better in some aspects of providing documentation in patient medical records compared with attending physicians; those using our EMR documentation tool performed best. We suggest use of a prompted or formatted guide for medical record documentation or dictation.

Consistent with physician behaviors seen in prior studies,5- 7 our attending physicians were not judicious in ordering urine dipstick analyses, formal urine analyses, or urine cultures. Many dipstick tests were ordered for patients who, based on history and examination, already had a 90% probability of UTI. 5 Despite the high probability of disease evident from positive results on urine dipstick testing, physicians frequently ordered urine culture and sensitivity testing. Furthermore, despite the associated cost, time, and effort, urine culture results did not necessitate change in treatment for any of our patients with uncomplicated UTI.

Treatment with SMX-TMP was not provided for most of our patients even though this has been recommended as the first-line antimicrobial agent by multiple guidelines. For example, the Infectious Diseases Society of America recommends that SMX-TMP is the treatment of choice in areas where the rate of E coli sensitivity is 80% or greater.2 Our results were similar to those of McEwen et al, 7 who reported that 37% of physicians prescribe SMX-TMP for uncomplicated UTI. We not only underprescribed SMX-TMP but also overprescribed fluoroquinolones. This was especially true among our attending physicians.

Our prescribed duration of therapy was often longer than the recommended 3 days. Of the 62 patients treated with SMX-TMP or ciprofloxacin, 24 (39%) were given antibiotic courses for more than 3 days. Kahan et al 11 reported that, even when physicians choose an appropriate antibiotic, duration of therapy was incorrect a vast majority of the time.

Physicians may be using sensitivity data from their hospitalized patients to guide empirical treatment of their outpatients with UTI. Although we have seen increasing resistance of E coli to SMX-TMP in the inpatient setting, our findings in the outpatient setting for uncomplicated UTI were significantly different. It has been recommended that physicians monitor resistance patterns in their own patient populations to determine whether SMX-TMP is an appropriate choice in their setting. 8,12

Simple changes in our practice environment may decrease costs and simplify care. Having the ability to order a formal urinalysis with completion of culture only when the number of epithelial cells seen on microscopy is small would be helpful (ie, a urinalysis with reflex culture). Eleven (21%) of 52 cultures in this low-risk patient group had mixed flora, indicating contamination.

Limitations

Our physicians ordered urine cultures frequently and did not prescribe SMX-TMP appropriately. These behaviors may be explained by the fact that our patient population is older and medically complicated. It appears that we often treat patients with uncomplicated UTI in a manner advocated for complicated UTI. Our rate of SMX-TMP use may be artificially low due to the fact that we did not account for the presence of medication allergies, intolerances, or contraindications. We did not account for the effect of patient preferences or past experiences in the decision about treatment options. One hundred percent compliance with all aspects of clinical guidelines may not be a reasonable or even desirable goal.

Some practice guidelines also allow for the use of telephone triage and empirical treatment of uncomplicated UTI without a clinical visit. 3,13 We excluded these interactions from this analysis and believe that this was an infrequent occurrence in our practice.

Future Research

Now that we have determined our baseline behaviors, we plan to provide educational interventions in hopes of seeing changes in our physicians' practice patterns. We hope to be able to decrease the frequency with which urine culture and sensitivity analysis is being used as a diagnostic tool in uncomplicated UTI and increase the frequency of 3-day treatment with SMX-TMP. Also, we plan to evaluate our management of patients older then 65 years as they account for nearly half of our patients with UTI. Determining whether antibiotic resistance on urine culture and sensitivity analysis is a function purely of age or instead is due to the medical complications of a specific patient would be helpful in making decisions about the utility of diagnostic testing.


CONCLUSION


Discrepancies exist between physician practice behaviors and published guidelines. Using these evidence-based algorithms for the diagnosis and management of UTI can be helpful only when one carefully assesses patients for complicating factors. Only 30% of our patients had uncomplicated UTI, making their management within clinical guidelines appropriate. However, of those patients with uncomplicated UTI, less than 25% received empirical treatment as suggested. Urine culture and sensitivity analyses were performed frequently, even in patients who already had positive results on a urine dipstick analysis. Although SMX-TMP is effective, it is underused. We hope to improve adherence to published guidelines through education and practice support. We suggest that medical groups review their own patient populations and practice behaviors through similar quality improvement processes.

REFERENCES

Centers for Disease Control and Prevention, US Department of Health and Human Services. Ambulatory Care Visits to Physician Offices, Hospital Outpatient Departments, and Emergency Departments: United States, 1999-2000. Available at: www.cdc.gov/nchs/data/series/sr_13/sr13_157.pdf. Accessed December 21, 2006.


Warren JW, Abrutyn E, Hebel JR, Johnson JR, Schaeffer AJ, Stamm WE. Guidelines for antimicrobial treatment of uncomplicated acute bacterial cystitis and acute pyelonephritis in women: Infectious Diseases Society of America (IDSA). Clin Infect Dis. 1999;29:745-758.


Kasten MJ, Gravley E, Olson D, et al. ICSI Health Care Guideline: Uncomplicated Urinary Tract Infection in Women. Bloomington, MN: Institute for Clinical Systems Improvement. Available from: www.icsi.org/knowledge/detail.asp?catID=29&itemID=200 . Accessed December 21, 2006.


Mehnert-Kay SA. Diagnosis and management of uncomplicated urinary tract infections. Am Fam Physician. 2005;72:451-456.


Bent S, Nallamothu BK, Simel DL, Fihn SD, Saint S. Does this woman have an acute uncomplicated urinary tract infection? JAMA. 2002;287:2701-2710.


Wigton RS, Longenecker JC, Bryan TJ, Parenti C, Flash SD, Tape TG. Variation by specialty in the treatment of urinary tract infection in women. J Gen Intern Med. 1999;14:491-494.


McEwen LN, Farjo R, Foxman B. Antibiotic prescribing for cystitis: how well does it match published guidelines? Ann Epidemiol. 2003;13:479-483.


Raz R, Chazan B, Kennes Y, et al, Israeli Urinary Tract Infection Group. Empiric use of trimethoprim-sulfamethoxazole (TMP-SMX) in the treatment of women with uncomplicated urinary tract infections, in a geographical area with high prevalence of TMP-SMX-resistant uropathogens. Clin Infect Dis. 2002 May 1;34:1165-1169. Epub 2002 Apr 4.


Kahan NR, Friedman NL, Lomnicky Y, et al. Physician specialty and adherence to guidelines for the treatment of unsubstantiated uncomplicated urinary tract infection among women. Pharmacoepidemiol Drug Saf. 2005;14:357-361.


Kahan NR, Chinitz DP, Waitman DA, Kahan E. Empiric treatment of uncomplicated UTI in women: wasting money when more is not better. J Clin Pharmacol Ther. 2004;29:437-441.


Kahan NR, Chinitz DP, Kahan E. Physician adherence to recommendations for duration of empiric antibiotic treatment for uncomplicated urinary tract infection in women: a national drug utilization analysis. Pharmacoepidemiol Drug Saf. 2004;13:239-242.


Ansbach RK, Dybus K, Bergeson R. Uncomplicated E. coli urinary tract infection in college women: a follow-up study of E. coli sensitivities to commonly prescribed antibiotics. J Am Coll Health. 2005;54:81-84.


Saint S, Scholes D, Fihn SD, Farrell RG, Stamm WE. The effectiveness of a clinical practice guideline for the management of uncomplicated urinary tract infection in women. Am J Med. 1999;106:636-641.