Adequacy of an evidence-based treatment guideline for complicated urinary tract infections in the Netherlands and the effectiveness of guideline adherence

Abstract

Guideline recommendations on empirical antibiotic treatment are based on the literature, expert opinion, expected pathogens and resistance data, but their adequacy in the real-life setting is often unknown. We investigated the adequacy of the Dutch evidence-based guideline-recommended treatment options for patients with complicated urinary tract infections (UTIs) 2 years after guideline publication and, additionally, the adequacy of actually prescribed empirical therapy for patients treated with guideline-adherent versus non-guideline-adherent therapy. A retrospective, observational multicentre study in the Netherlands included 810 patients with a complicated UTI without special conditions and 174 with a urinary catheter. The susceptibility patterns of cultured uropathogens were compared with guideline-recommended treatment options, which included specific recommendations for patients with a catheter, and with actually prescribed empirical therapy. We considered inadequate coverage rates below 10% as acceptable. Of the recommended regimens for patients with a UTI without other conditions, only the guideline-recommended combination of amoxicillin-gentamicin was acceptable (inadequate coverage rate 6%). For patients with a catheter, inadequate coverage rates of recommended regimens ranged from 3 to 24%. In patients with a UTI without other conditions, actually prescribed guideline-adherent therapy resulted in less broad-spectrum but not in less adequate therapy; in patients with a catheter, actually prescribed guideline-adherent therapy resulted in a higher coverage rate than those prescribed non-guideline-adherent therapy. Due to the continuously changing resistance rates and differences between the epidemiologies of uropathogens assumed in the guideline and those in real life, regular real-life assessments of recommended treatment options are necessary. Guideline adherence seems to be effective for increasing coverage rates without prescribing unnecessarily broad regimens.

Appropriate Antibiotic Use for Patients With Urinary Tract Infections Reduces Length of Hospital Stay

“…For complicated UTIs fewer studies are available, but 2 studies showed a relation between inadequate antibiotic therapy (ie, not covering the in vitro susceptibility of the isolated pathogens) and increased LOS in specific subgroups of UTI patients [6,7]. In the same patient cohort, we showed that guideline adherence indeed increased the percentage of patients receiving adequate antibiotic therapy [18]; hence, a positive effect of guideline adherence on LOS in UTI patients seems plausible.…”

Lack of Clinical Utility of Urine Gram Stain for Suspected Urinary Tract Infection in Pediatric Patients

“…The results of the Gram stain have been shown to affect prescribing patterns for adult patients with pneumonia or UTI (19). However, antibiotic selection for UTI in pediatrics has historically been driven by local resistance patterns and institutional prescribing guidelines rather than the results of urine Gram stain (20,21). Additionally, antibacterials used in the management of UTI generally achieve very high urinary concentrations, making precise empirical pathogen targeting unnecessary (22).…”

The additional value of blood cultures in patients with complicated urinary tract infections

“…We conducted a retrospective observational cohort study, which was part of the baseline measurement of a cluster‐randomized trial testing a multifaceted antibiotic stewardship programme in patients with a complicated UTI. The details have been described before . Briefly, the departments of internal medicine and urology of 19 hospitals located throughout the Netherlands participated.…”

“…Briefly, the departments of internal medicine and urology of 19 hospitals located throughout the Netherlands participated. Included were adult inpatients/outpatients diagnosed with a complicated UTI, including uncomplicated pyelonephritis , who started antibiotic therapy. For the present study, we only considered those hospitalized patients for whom both a blood culture and a urine culture were obtained on first day of antibiotic treatment.…”