Getting with UTI Treatment Guidelines

Daniel J. Pallin, MD, MPH reviewing Percival KM et al. Am J Emerg Med 2015 Sep.

An educational intervention in an emergency department led to improvements in guideline-concordant antibiotic selection for urinary tract infections.

The Infectious Diseases Society of America guidelines for treating uncomplicated urinary tract infections (UTIs) recommend that nitrofurantoin be used as first-line therapy for cystitis, except when renal insufficiency is present, and that cephalexin be considered as an acceptable alternative. Trimethoprim-sulfamethoxazole and ciprofloxacin are recommended as second- and third-line options, respectively. For pyelonephritis, intravenous ceftriaxone (1g) is recommended when fluoroquinolone resistance exceeds 10%, and outpatient therapy should be with ciprofloxacin; trimethoprim-sulfamethoxazole and cephalexin are second-line options. Customizing treatment choices based on local antibiograms is emphasized.

Now, investigators at a single academic emergency department (ED) have conducted a study to test whether an educational intervention would improve adherence to these guidelines. The researchers worked with the hospital's microbiology laboratory to create an ED-specific antibiogram and then educated residents and attendings about the recommendations. They then compared medical records of 174 patients who were treated before the intervention and 176 who were treated after the intervention. Of these patients, 255 had cystitis, and 95 had pyelonephritis.

Guideline-concurrent therapy increased from 45% of cases preintervention to 83% postintervention. This improvement was largely due to an increase in nitrofurantoin use for cystitis, from 12% to 80%. The rate at which isolated pathogens were susceptible to prescribed antibiotics improved from 74% preintervention to 89% postintervention. There was no change in 30-day repeat visits for UTIs.

Citation(s):

Percival KM et al. Impact of an antimicrobial stewardship intervention on urinary tract infection treatment in the ED. Am J Emerg Med 2015 Sep; 33:1129.