Variation by specialty in the treatment of urinary tract infection in women

Abstract

To determine practicing physicians' strategies for diagnosing and managing uncomplicated urinary tract infection, we surveyed physicians in general internal medicine, family practice, obstetrics and gynecology, and emergency medicine in four states. Responses differed significantly by respondents' specialty. For example, nitrofurantoin was the antibiotic of first choice for 46% of obstetricians, while over 80% in the other specialties chose trimethoprim-sulfamethoxazole. Most surveyed said they do not usually order urine culture, but the percentage who do varied by specialty. Most use a colony count of 10 5 colony-forming units or more for diagnosis although evidence favors a lower threshold, and 70% continue antibiotic therapy even if the culture result is negative. This survey found considerable variation by specialty and also among individual physicians regarding diagnosis and treatment of urinary tract infection and also suggests that some of the new information from the literature has not been translated to clinical practice. H ow physicians diagnose and treat uncomplicated urinary tract infection (UTI) can affect patient care and health care costs. Because UTI is a frequent complaint, even small variations in charges for diagnosis and treatment can account for large differences in expense when aggregated over millions of cases. Surveys have found that physicians vary in their approach to UTI. [1][2][3] Despite its importance, there is little information on what strategies physicians in the United States use in working up suspected UTI in women. KEY WORDS: urinary tract infectionResearch over the past 15 years has introduced new information regarding the diagnosis and management of UTI. Stamm and colleagues, for example, showed that a lower colony count than previously thought predicts bladder bacteriuria in symptomatic women. 4,5 Investigators have demonstrated the effectiveness and safety of shorter courses of treatment for acute cystitis, 6 and have developed convenient dipstick tests for pyuria and bacteriuria. 7 Investigators have increasingly questioned the need for culture and sensitivity of the urine in uncomplicated cases. 6,8 In addition, there is evidence that diagnostic strategies are changing, driven in part by mandates to reduce unnecessary costs. 9 To develop a broader understanding of physicians' diagnostic and management strategies and to determine whether these new advances have found their way into practice, we surveyed practicing physicians in several states and compared their strategies by possible sources of variation such as specialty, date of medical training, and practice location. METHODSWe developed an 88-item survey that was based on a review of the literature and interviews with generalist physicians. The 4-page survey asked about the value of clinical finding, tests, and strategies in the diagnosis and management of a 30-year-old nonpregnant woman with uncomplicated UTI with dysuria of recent onset.We surveyed physicians in specialties likely to be primary providers for adult w...

Validation of a Decision Aid to Assist Physicians in Reducing Unnecessary Antibiotic Drug Use for Acute Cystitis

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“…5 This latter approach was associated with a high rate of unnecessary antibiotic use in the present study. In the context of increasing uropathogen antibiotic resistance 19 and lack of clinical agreement about how to manage acute cystitis, 17,18 practical and validated strategies that can help physicians use antibiotics judiciously could be clinically useful.…”

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“…In the recent years, several studies have shown specific risk factors for recurrent AUC [7,8] and large studies revealed its microbial etiology. Clinical tests for diagnosing AUC vary widely, depending on comorbidities and different treatment strategies [9,10,11]. …”

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“…Often this test is used in conjunction with or in place of a urine culture in the diagnosis of a UTI. However, a recent study found many practicing clinicians use different standards to determine the presence or absence of a UTI, most not updated on current literature 3 . To further complicate matters, the level of automation in urinalysis is increasing and accepted cut-off values differ for these more sensitive methods.…”