In the JournalsPerspective

UTIs increasingly diagnosed in virtual care setting

Katia J. Bruxvoort, PhD, MPH
Katia J. Bruxvoort

The rate of UTIs diagnosed in the outpatient setting increased between 2008 and 2017, especially among older adults and in patients receiving virtual care, researchers reported in Clinical Infectious Diseases.

The researchers observed increasing diagnoses of UTIs in virtual visits compared with office and emergency visits. Specifically, the rate of UTIs by diagnosis code with antibiotic increased annually by 21.2% (95% CI, 16.5%-26.2%) among women and 29.3% (95% CI, 23.7%-35.3%) among men. Most virtual care diagnoses did not include a culture order.

“Virtual health care has been shown to provide greater convenience and cost savings, but this research shows that there is potential for overdiagnosis of UTI,” Katia J. Bruxvoort, PhD, MPH, infectious disease epidemiologist and research fellow in the department of research and evaluation at Kaiser Permanente Southern California, told Infectious Disease News.

Using electronic health record data at Kaiser Permanente Southern California, Bruxvoort and colleagues identified UTIs diagnosed in outpatient settings, including office, emergency and virtual visits, between Jan. 1, 2008, and Dec. 31, 2017.

The data revealed that 1,065,955 individuals were diagnosed with a UTI during the study period. When determined by diagnosis code with antibiotic, the rate per 1,000 person-years was 53.7 (95% CI, 50.6-57), and by positive culture the rate per 1,000 person-years was 25.8 (95% CI, 24.7-26.9).

Of the virtual care orders, only 32% had a culture order, according to the study.

Treatment of UTI without conducting a urine culture is routine practice for patients without complications,” Bruxvoort said. “While this is consistent with clinical recommendations, our study suggests that this practice may inadvertently contribute to overtreatment with antibiotics in some patients.

Bruxvoort and colleagues noted that the rate of UTIs was shown to be the highest in older adults overall, and this population also had the most increase in rates over the study period. Hispanic and white women and black and white men also had high rates of UTIs, the researchers said.

The findings suggested that outpatient settings need strategies in place to ensure the accuracy of UTI diagnoses as well as reduce inappropriate antibiotic prescribing.

“Overuse of antibiotics can contribute to the development of antibiotic resistance, and it is important to make sure we are being good stewards and only using them when necessary,” Bruxvoort said. “Future research is needed to explore reasons for the increase in outpatient UTI rates. We also are exploring strategies for improving diagnosis of UTI and ensuring appropriate and judicious use of antibiotics in all health care settings, including virtual care.” – by Marley Ghizzone

Disclosures: The authors report no relevant financial disclosures.

Katia J. Bruxvoort, PhD, MPH
Katia J. Bruxvoort

The rate of UTIs diagnosed in the outpatient setting increased between 2008 and 2017, especially among older adults and in patients receiving virtual care, researchers reported in Clinical Infectious Diseases.

The researchers observed increasing diagnoses of UTIs in virtual visits compared with office and emergency visits. Specifically, the rate of UTIs by diagnosis code with antibiotic increased annually by 21.2% (95% CI, 16.5%-26.2%) among women and 29.3% (95% CI, 23.7%-35.3%) among men. Most virtual care diagnoses did not include a culture order.

“Virtual health care has been shown to provide greater convenience and cost savings, but this research shows that there is potential for overdiagnosis of UTI,” Katia J. Bruxvoort, PhD, MPH, infectious disease epidemiologist and research fellow in the department of research and evaluation at Kaiser Permanente Southern California, told Infectious Disease News.

Using electronic health record data at Kaiser Permanente Southern California, Bruxvoort and colleagues identified UTIs diagnosed in outpatient settings, including office, emergency and virtual visits, between Jan. 1, 2008, and Dec. 31, 2017.

The data revealed that 1,065,955 individuals were diagnosed with a UTI during the study period. When determined by diagnosis code with antibiotic, the rate per 1,000 person-years was 53.7 (95% CI, 50.6-57), and by positive culture the rate per 1,000 person-years was 25.8 (95% CI, 24.7-26.9).

Of the virtual care orders, only 32% had a culture order, according to the study.

Treatment of UTI without conducting a urine culture is routine practice for patients without complications,” Bruxvoort said. “While this is consistent with clinical recommendations, our study suggests that this practice may inadvertently contribute to overtreatment with antibiotics in some patients.

Bruxvoort and colleagues noted that the rate of UTIs was shown to be the highest in older adults overall, and this population also had the most increase in rates over the study period. Hispanic and white women and black and white men also had high rates of UTIs, the researchers said.

The findings suggested that outpatient settings need strategies in place to ensure the accuracy of UTI diagnoses as well as reduce inappropriate antibiotic prescribing.

“Overuse of antibiotics can contribute to the development of antibiotic resistance, and it is important to make sure we are being good stewards and only using them when necessary,” Bruxvoort said. “Future research is needed to explore reasons for the increase in outpatient UTI rates. We also are exploring strategies for improving diagnosis of UTI and ensuring appropriate and judicious use of antibiotics in all health care settings, including virtual care.” – by Marley Ghizzone

Disclosures: The authors report no relevant financial disclosures.

    Perspective
    Michael S. Calderwood

    Michael S. Calderwood

    In younger women with classic symptoms of an uncomplicated UTI, studies have supported diagnosis and treatment via phone consultation, as opposed to requiring an office visit for an exam, urinalysis and urine culture. What the paper by Bruxvoort and colleagues shows is that these types of “virtual visits” have been increasing annually from 2008 through 2017, and although this can be convenient for patients, a higher percentage of patients are prescribed an antibiotic during one of these “virtual visits” than during a standard office visit. This raises concern for potential overprescribing of antibiotics and selection of drug-resistant bacteria.

    One particularly noteworthy finding in the paper by Bruxvoort and colleagues is that the diagnosis of UTIs in patients aged older than 85 has risen the most, as has the number of positive urine cultures per 1,000 people in this age group. This is important, because up to 10% to 20% of people aged older than 60 have transient asymptomatic bacteriuria, with rates up to 40% to 50% in women aged older than 80 and in patients who are in nursing homes. Urine cultures in these older patients are often sent based on appearance or odor, better indicators of dehydration rather than UTI. Similarly, mental status change can be a sign of dehydration rather than UTI.

    Among older adults (aged 65 and older), 42% of antibiotics are prescribed for conditions where “antibiotics not indicated.” In particular, fluoroquinolones have been shown to be one of the most commonly prescribed antibiotics in Medicare Part D enrollees. It is important to educate providers on appropriate prescribing practices, including the potential harms of overprescribing via “virtual visits.”

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    Gupta K, et al. Ann Intern Med. 2001;doi:10.7326/0003-4819-135-1-200107030-00004.

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    • Michael S. Calderwood, MD, MPH
    • Regional hospital epidemiologist, Dartmouth-Hitchcock Medical Center
      Associate professor of medicine, Geisel School of Medicine at Dartmouth

    Disclosures: Calderwood reports no relevant financial disclosures.