Use of diagnostic tests and the appropriateness of the treatment decision in patients with suspected urinary tract infection in primary care in Denmark – observational study

Abstract

BackgroundInappropriate prescription of antibiotics is the leading driver of antimicrobial resistance (AMR). The majority of antibiotics are prescribed in primary care.Understanding how general practitioners (GPs) use diagnostic tests and the effect on treatment decision under daily practice conditions is important to reduce inappropriate prescription of antibiotics. The aim of the study was to investigate the use of diagnostic tests in primary care patients with suspected urinary tract infection (UTI) and to assess the appropriateness of the treatment decision (TD) under daily practice conditions in Denmark.MethodsProspective observational study. Symptomatic adult patients consulting general practice with suspected UTI recruited over 12 months. The diagnostic workup was registered in a standardized form. The appropriateness of the TD was assessed based on the results of a culture performed at a reference microbiological laboratory. TD was considered appropriate if a patient had a positive culture and was prescribed antibiotics or had a negative culture and was not prescribed antibiotics. TD was considered inappropriate if a patient had a negative culture and was prescribed antibiotics (overtreatment) or had a positive culture and was not prescribed antibiotics (undertreatment).ResultsFour hundred and eighty-eight patients were included. Dipstick was used in 98% of the patients and urine culture was used in 89% of the patients; 317 had the culture performed in practice and 117 had the culture performed at the hospital. The appropriateness of the final TD was significantly (p = 0.04) lower in patients without culture (55%) than in patients with culture performed in practice (71%) or at hospital (69%).ConclusionIn a context with wide availability of diagnostic tests, GPs use diagnostic tests for the decision-making process in all patients with suspected UTI. Urine culture is used in the majority of the patients and is associated with a higher proportion of appropriate treatment decisions. Performance of urine culture is therefore important in reducing inappropriate antibiotic prescribing in patients with suspected UTI seeking care in general practice in Denmark.Trial registrationClinicalTrials.gov NCT02249273.Electronic supplementary materialThe online version of this article (10.1186/s12875-018-0754-1) contains supplementary material, which is available to authorized users.

Workload, diagnostic work-up and treatment of urinary tract infections in adults during out-of-hours primary care: a retrospective cohort study

“…As hypothesised, our study showed an even lower number of correctly ordered cultures of one out of ten patients [4,8,23]. This is far below the one out of three that was found in an earlier study during office hours [4].…”

“…One can assume that with acute onset of symptoms, and daytime GP practices only open during at best 30% of the 168 h in a week, a large proportion of UTI management happens at the out-of-hours care [20]. Earlier studies on UTI diagnostics have only focused on appropriateness of current diagnostic tests during daytime practice [4,8,20]. None of these studies analysed the diagnostic process of UTIs during out-of-hours care.…”

Validity of microscopy for diagnosing urinary tract infection in general practice – a systematic review

“…A systematic review from 2010 found that using urine microscopy as an add-on to urine dipstick slightly improved the sensitivity [6]. However, this combination still seems to be inferior to urine culture in order to avoid over-diagnosis [26].…”

Overdiagnosis paradigm: not suitable for decreasing the overuse of antibiotics

“…One of the few countries with the wide availability of rapid tests is Denmark. This scenario allowed us to assess the use of diagnostic tools in daily practice and its effect on treatment decision in patients with suspected urinary tract infection (UTI) 25. We found that in 85% of the patients with a suspected uncomplicated UTI, urine culture was part of the diagnostic process.…”