A single center observational study on emergency department clinician non-adherence to clinical practice guidelines for treatment of uncomplicated urinary tract infections.

Mark Zocchi,Larissa May,Gillian Brooks,Cynthia Rand,Sara E Cosgrove,Catherine Zatorski

doi:10.1186/s12879-016-1972-6

Abstract

BackgroundThe Emergency Department (ED) is a frequent site of antibiotic use; poor adherence with evidence-based guidelines and broad-spectrum antibiotic overuse is common. Our objective was to determine rates and predictors of inappropriate antimicrobial use in patients with uncomplicated urinary tract infections (UTI) compared to the 2010 International Clinical Practice Guidelines (ICPG).MethodsA single center, prospective, observational study of patients with uncomplicated UTI presenting to an urban ED between September 2012 and February 2014 that examined ED physician adherence to ICPG when treating uncomplicated UTIs. Clinician-directed antibiotic treatment was compared to the ICPG using a standardized case definition for non-adherence. Binomial confidence intervals and student’s t-tests were performed to evaluate differences in demographic characteristics and management between patients with pyelonephritis versus cystitis. Regression models were used to analyze the significance of various predictors to non-adherent treatment.Results103 cases met the inclusion and exclusion criteria, with 63.1 % receiving non-adherent treatment, most commonly use of a fluoroquinolone (FQ) in cases with cystitis (97.6 %). In cases with pyelonephritis, inappropriate antibiotic choice (39.1 %) and no initial IV antibiotic for pyelonephritis (39.1 %) where recommended were the most common characterizations of non-adherence. Overall, cases of cystitis were no more/less likely to receive non-adherent treatment than cases of pyelonephritis (OR 0.9, 95 % confidence interval 0.4–2.2, P = 0.90). In multivariable analysis, patients more likely to receive non-adherent treatment included those without a recent history of a UTI (OR 3.8, 95 % CI 1.3–11.4, P = 0.02) and cystitis cases with back or abdominal pain only (OR 11.4, 95 % CI 2.1–63.0, P = 0.01).ConclusionsPatients with cystitis with back or abdominal pain only were most likely to receive non-adherent treatment, potentially suggesting diagnostic inaccuracy. Physician education on evidence-based guidelines regarding the treatment of uncomplicated UTI will decrease broad-spectrum use and drug resistance in uropathogens.

Highlights

The Emergency Department (ED) is a frequent site of antibiotic use; poor adherence with evidencebased guidelines and broad-spectrum antibiotic overuse is common
The natural limitations of the ED setting, such as inadequate microbiological testing and follow up, necessitates the use of treatment recommendations based on clinical findings in evidence based guidelines (EBG) to minimize antimicrobial resistance and adverse events associated with broad spectrum antibiotic use
At our site care for uncomplicated urinary tract infections (UTI) is primarily performed in the ED ambulatory care track by emergency medicine (EM) trained physicians and physician assistants (PA); EM residents (Post Graduate Years 1 through 4) and non-EM residents who rotate in the ED and provide care

Summary

Introduction

The Emergency Department (ED) is a frequent site of antibiotic use; poor adherence with evidencebased guidelines and broad-spectrum antibiotic overuse is common. Our objective was to determine rates and predictors of inappropriate antimicrobial use in patients with uncomplicated urinary tract infections (UTI) compared to the 2010 International Clinical Practice Guidelines (ICPG). Up to half of all antimicrobial prescriptions are inappropriate [3], with poor adherence with evidence based guidelines (EBG) for infectious diseases [4, 5] and overuse of broad spectrum antibiotics [6, 7]; this has not been quantified in an ED setting. The natural limitations of the ED setting, such as inadequate microbiological testing and follow up, necessitates the use of treatment recommendations based on clinical findings in EBGs to minimize antimicrobial resistance and adverse events associated with broad spectrum antibiotic use

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