Antimicrobial Stewardship through the Characterization of Inappropriate Antibiotic Therapy for Urinary Tract Infections in the Emergency Department (ED)

Background:  

Urinary tract infections (UTI) account for > 25 million visits to the ED per year.[1]  According to 2011 IDSA guidelines for non-complicated UTI, fluoroquinolones (FQ) should not be first line for patients without fever or flank pain.[2]For patients with symptoms of pyelonephritis, FQ are the preferred choice where community resistance rates are <10%. Our objectives were to determine adherence and describe non-adherence to guidelines in an urban academic ED for UTI. 

Methods:

 

Ongoing enrollment in ED of women 18-65 years of age with complaints consistent with UTI.  Exclusion criteria included: recurrent UTI, pregnancy, indwelling catheters, diabetes, immunosuppressed state, and admission to hospital.  Clinical and demographic characteristics were collected via structured data form and chart abstraction.   Antibiotic choice, dose, and duration were compared to guidelines to determine adherence.

Results:

Of 75 enrolled patients, 34 patients were excluded from analysis due to a final diagnosis of non UTI-related illness or complicated UTI.  Our interim analysis showed of the 41 included patients, 62.5% received treatment that did not adhere to guidelines. 50% of non-adherent cases were due to antibiotic choice; 90% of these were for FQ use.  Attendings seeing patients alone were more likely to be non-adherent than residents or physician assistants under supervision (risk measure, p=0.046)

Conclusion:

Of the 25 patients who received non-adherent treatment, the most common reason was use of a FQ.  While attendings were more likely to prescribe FQ, other predictors have not yet been identified; ongoing enrollment will allow sufficient sample size to assess other potential associations.

[1] Caterino JM, Ting SA, Sisbarro SG, Espinola JA, Camargo CA Jr. Age, nursing home residence, and presentation of urinary tract infection in U.S. emergency departments, 2001-2008.  Acad Emerg Med.  2012 Oct;19(10):1173-80. doi: 10.1111/j.1553-2712.2012.01452.x.

[2] Gupta, K Hooton T, Naber I, et al. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. CID. 2011; 52: 111-120.