In the JournalsPerspective

Same-day antibiotics prescribed for 85% of UTIs in British study

Mar Pujades-Rodriguez, PhD, MSc
Mar Pujades-Rodriguez

Study findings published in EClincialMedicine showed that more than 85% of patients in England who are diagnosed with a lower UTI in primary care receive an antibiotic on the same day, and that most do not have a recorded urine test within 10 days of diagnosis.

“We found that less than one in five patients treated for a UTI in primary care had a laboratory urine test to diagnose their problem,” Mar Pujades-Rodriguez, PhD, MSc, a clinical epidemiologist at the University of Leeds, told Infectious Disease News. “Existing laboratory tests for UTIs are therefore having little impact on the prescribing of antibiotics.”

According to Pujades-Rodriguez, current bedside dipstick tests to screen urine samples for infection are inaccurate and laboratory tests are slow. It takes between 2 and 3 days for currently available laboratory tests to determine a UTI pathogen and its antibiotic susceptibilities, she said.

The U.K.’s National Institute for Health and Care Excellence last year issued national clinical guidelines recommending narrow spectrum antibiotics to treat lower UTIs, particularly trimethoprim or nitrofurantoin. The guidelines stress that these should be offered only when the risk for resistance is low, and doctors should consider previous antibiotic use and previous urine culture and sensitivity results before recommending them.

Pujades-Rodriguez and colleagues identified a cohort of 300,354 patients and a total of 494,675 lower UTI diagnoses between 2011 and 2015 from the 390 primary care practices that contribute data to England’s ResearchOne database.

They examined investigation, antibiotic treatment and antibiotic re-prescription within 28 days according to guideline-defined patient groups and used mixed-effect logistic regression to assess risk factors for re-prescription.

The median patient age was 54 years, and 83.3% were women, according to the study. A same-day antibiotic was prescribed for 85.7% of UTIs. The most commonly prescribed initial antibiotic was trimethoprim (56.8%), followed by nitrofurantoin (23.9%). Urine sampling was undertaken in 25% of patients. Most — 83% — did not have evidence of a urine test in their electronic health records.

Pujades-Rodriguez and colleagues reported a low antibiotic re-prescription rate of 17,430 (4.1%), increasing slightly over time from 5.2% in 2011 to 6.2% in 2015. Overall, 21.1% of re-prescriptions were for the same antibiotic, they wrote. The risk of antibiotic re-prescription increased with age, calendar year, recent antibiotic prescribing and treatment with an antibiotic other than trimethoprim or nitrofurantoin.

“Thousands of people across England have been given repeat prescriptions that have little chance of curing their infection and may increase the risk for the development of antibiotic resistance,” Pujades-Rodriguez said. “Because UTIs are one of the most common reasons that antibiotics are prescribed, the potential contribution of such practices to antibiotic resistance could be significant.” – by Joe Gramigna

Reference:

National Institute for Health and Care Excellence. Urinary tract infection (lower): antimicrobial prescribing. https://www.nice.org.uk/guidance/ng109. Accessed August 14, 2019.

Disclosures: The authors report support from the U.K. National Health Service Improvement. Please see the study for all authors’ relevant financial disclosures.

Mar Pujades-Rodriguez, PhD, MSc
Mar Pujades-Rodriguez

Study findings published in EClincialMedicine showed that more than 85% of patients in England who are diagnosed with a lower UTI in primary care receive an antibiotic on the same day, and that most do not have a recorded urine test within 10 days of diagnosis.

“We found that less than one in five patients treated for a UTI in primary care had a laboratory urine test to diagnose their problem,” Mar Pujades-Rodriguez, PhD, MSc, a clinical epidemiologist at the University of Leeds, told Infectious Disease News. “Existing laboratory tests for UTIs are therefore having little impact on the prescribing of antibiotics.”

According to Pujades-Rodriguez, current bedside dipstick tests to screen urine samples for infection are inaccurate and laboratory tests are slow. It takes between 2 and 3 days for currently available laboratory tests to determine a UTI pathogen and its antibiotic susceptibilities, she said.

The U.K.’s National Institute for Health and Care Excellence last year issued national clinical guidelines recommending narrow spectrum antibiotics to treat lower UTIs, particularly trimethoprim or nitrofurantoin. The guidelines stress that these should be offered only when the risk for resistance is low, and doctors should consider previous antibiotic use and previous urine culture and sensitivity results before recommending them.

Pujades-Rodriguez and colleagues identified a cohort of 300,354 patients and a total of 494,675 lower UTI diagnoses between 2011 and 2015 from the 390 primary care practices that contribute data to England’s ResearchOne database.

They examined investigation, antibiotic treatment and antibiotic re-prescription within 28 days according to guideline-defined patient groups and used mixed-effect logistic regression to assess risk factors for re-prescription.

The median patient age was 54 years, and 83.3% were women, according to the study. A same-day antibiotic was prescribed for 85.7% of UTIs. The most commonly prescribed initial antibiotic was trimethoprim (56.8%), followed by nitrofurantoin (23.9%). Urine sampling was undertaken in 25% of patients. Most — 83% — did not have evidence of a urine test in their electronic health records.

Pujades-Rodriguez and colleagues reported a low antibiotic re-prescription rate of 17,430 (4.1%), increasing slightly over time from 5.2% in 2011 to 6.2% in 2015. Overall, 21.1% of re-prescriptions were for the same antibiotic, they wrote. The risk of antibiotic re-prescription increased with age, calendar year, recent antibiotic prescribing and treatment with an antibiotic other than trimethoprim or nitrofurantoin.

“Thousands of people across England have been given repeat prescriptions that have little chance of curing their infection and may increase the risk for the development of antibiotic resistance,” Pujades-Rodriguez said. “Because UTIs are one of the most common reasons that antibiotics are prescribed, the potential contribution of such practices to antibiotic resistance could be significant.” – by Joe Gramigna

Reference:

National Institute for Health and Care Excellence. Urinary tract infection (lower): antimicrobial prescribing. https://www.nice.org.uk/guidance/ng109. Accessed August 14, 2019.

Disclosures: The authors report support from the U.K. National Health Service Improvement. Please see the study for all authors’ relevant financial disclosures.

    Perspective
    Aaron Glatt

    Aaron Glatt

    Although this is an important addition to the literature, this paper must be understood within the context of the population evaluated and within the limits of this type of retrospective, noninterventional cohort study. Indeed, many of the patients in the cohort were women aged 18 to 64 years with an average of only one UTI per year, and there was no standard definition even used to define entry into the cohort other than having a diagnostic code for any type of UTI. 

    Furthermore, the authors noted that “analysis of data collected was part of routine clinical primary care practice, and was therefore not specifically gathered for research purposes.” Therefore, their findings that most women did not receive any microbiological evaluation and that empiric therapy was used (and was mostly effective, based upon low re-prescription rates) does not necessarily reflect optimal practice and should not be generalizable to all patient populations. 

    Additional significant limitations of this study include that no data were provided regarding urinary dipstick examination, which was not coded in this cohort, and that some patients had urinary catheters. Plus, the authors themselves also noted they were unable to take into account potential antibiotic resistance concerns of the prescriber, or even whether such risk factors were present because of the nature of this cohort study. They were likewise unable to assess dose-response associations because of lack of information on antibiotic dose and duration. Finally, their study did not exclude other infections, so it is possible that some of the antibiotic prescriptions were actually administered to treat a concomitant non-UTI infection. 

    The bottom line is this: Many women presenting with clear cut signs and symptoms of UTI, without a history of prior/regular UTIs, STDs, known anatomical abnormalities and/or other significant risk factors or conditions predisposing to significant resistance concerns can be empirically treated with an appropriate antimicrobial regimen based upon the local resistance patterns. With the high urine antibiotic levels achievable with many antimicrobials, even "resistant" UTI organisms can sometimes be successfully treated with a "resistant" antibiotic because laboratory resistance is defined based upon lower concentrations achievable in the blood. 

    Although this study potentially supports empiric treatment practices in the subgroup I just described, it certainly cannot be used to recommend such empiric therapy without diagnostic evaluation in most other subgroups of patients. 

    • Aaron Glatt, MD, FACP, FIDSA, FSHE
    • Spokesperson, Infectious Diseases Society of America
      Chairman of medicine and chief of infectious diseases
      South Nassau Communities Hospital
      Oceanside, New York

    Disclosures: Glatt reports no relevant financial disclosures.