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Urinary tract infection in women—physician's preferences for treatment and adherence to guidelines: a national drug utilization study in a managed care setting

  • Pharmacoepidemiology and Prescription
  • Published:
European Journal of Clinical Pharmacology Aims and scope Submit manuscript

Abstract

Background

The treatment of urinary tract infection (UTI), the most common bacterial infection in most Western countries, is a global clinical and economic issue. Trimethoprim-sulfamethoxazole (TMP-SMX) and nitrofurantoin are the two drugs currently recommended in clinical guidelines in Israel for uncomplicated UTI in women.

Objectives

This study evaluates physician preferences for treatment and adherence to guidelines.

Method

Data were derived from the electronic records of Leumit Health Fund, one of four health management organizations in Israel. Non-pregnant women aged 18–75 years with a diagnosis of acute cystitis or UTI without risk factors for complicated UTI who were empirically treated with antibiotics from January 2001 to June 2002 were identified. The final sample comprised 7738 physician–patient encounters. Physician prescription behavior was analyzed by evaluating the proportion of treatments with each individual drug. A binary regression model was implemented to identify factors associated with suboptimal adherence to the guidelines.

Results

TMP-SMX was the most frequently prescribed drug (25.81%), followed by nitrofurantoin (14.71%), for a 40.52% rate of adherence to the guidelines [95% confidence interval (CI)=39.42, 41.61]. Drugs from the fluoroquinolone family were prescribed in 22.82% of cases. Prescription behavior was also influenced by non-clinical, non-pharmacological factors, such as physician specialty, geographic setting and patient age.

Conclusions

The majority of cases of UTI in the present study were not treated according to the current guidelines. Fluoroquinolones, though not recommended and relatively costly, were prescribed extensively. These results highlight the necessity for a remedial education program within the health care system designed to improve adherence to the guidelines for the treatment of UTI in women. As this issue is of global importance, this evaluation may serve as a model for similar studies in other settings or countries.

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References

  1. Nicolle LE (2001) Epidemiology of urinary tract infection. Infect Med 18:153–162

    Google Scholar 

  2. Peterson GM, Stanton LA, Bergin JK, Chapman GA (1997) Improving the prescribing of antibiotics for urinary tract infection. J Clin Pharm Ther 22:147–153

    PubMed  Google Scholar 

  3. Hooton TM, Stamm WE (1997) Diagnosis and treatment of uncomplicated urinary tract infection. Infect Dis Clin North Am 11:551–581

    CAS  PubMed  Google Scholar 

  4. Saint S, Scholes D, Fihn SD, Farrell RG, Stamm WE (1999) The effectiveness of a clinical practice guideline for the management of presumed uncomplicated urinary tract infection in women. Am J Med 106:636–641

    Article  CAS  PubMed  Google Scholar 

  5. Avorn J, Solomon DH (2000) Cultural and economic factors that (mis)shape antibiotic use: the nonpharmacologic basis of therapeutics. Ann Intern Med 133:128–135

    PubMed  Google Scholar 

  6. Berg AO (1991) Variation among family physicians' management strategies for lower urinary tract infection in women: a report from the Washington Family Physicians Collaborative Research Network. J Am Board Fam Pract 4:327–330

    CAS  PubMed  Google Scholar 

  7. Komaroff AL, Pass TM, McCue JD, Cohen AB, Hendricks TM, Friedland G (1978) Management strategies for urinary and vaginal infections. Arch Intern Med 138:1069–1973

    Article  CAS  PubMed  Google Scholar 

  8. Wigton RS, Longenecker JC, Bryan TJ, Parenti C, Flach SD, Tape TG (1999) Variation by specialty in the treatment of urinary tract infection in women. J Gen Intern Med 14:491–494

    Article  CAS  PubMed  Google Scholar 

  9. Huang ES, Stafford RS (2002) National patterns in the treatment of urinary tract infections in women by ambulatory care physicians. Arch Intern Med 162:41–47

    Article  PubMed  Google Scholar 

  10. Lambert BL, Salmon JW, Stubbings J, Gilomen-Study G, Valuck RJ, Kezlarian K (1997) Factors associated with antibiotic prescribing in a managed care setting: an explanatory investigation. Soc Sci Med 45:1767–1779

    Article  CAS  PubMed  Google Scholar 

  11. Gupta K, Hooton TM, Stamm WE (2001) Increasing antimicrobial resistance and the management of uncomplicated community acquired urinary tract infections. Ann Intern Med 135:41–50

    CAS  PubMed  Google Scholar 

  12. Gupta K, Scholes D, Stamm WE (1999) Increasing prevalence of antimicrobial resistance among uropathogens causing acute uncomplicated cystitis in women. JAMA 281:736–738

    Article  CAS  PubMed  Google Scholar 

  13. Stamm WE (2002) Scientific and clinical challenges in the management of urinary tract infections. Am J Med 113:1S–4S

    Article  Google Scholar 

  14. McGavock H (2002) Editorial. Pharmacoepidemiol Drug Saf 11:407–408

    Article  PubMed  Google Scholar 

  15. Hawkes CA (2000) Antibiotic resistance: a clinician's perspective. Military Med 165[Suppl 2]:43–45

    Google Scholar 

  16. Stamm WE, Hooton TM (1993) Management of urinary tract infections in adults. N Engl J Med 329:1328–1334

    Google Scholar 

  17. National Guidelines Clearinghouse. (2002)http://www.guidelines.gov/FRAMESETS/guidelines_fs.asp?guideline=001510&Search_string=uti

  18. Warren JW, Abrutyn E, Hebel JR, Johnson JR, Schaeffer AJ, Stamm W (1999) Guidelines for antimicrobial treatment of uncomplicated acute bacterial cystitis and acute pyelonephritis in women. Clin Infect Dis 29:745–758

    CAS  PubMed  Google Scholar 

  19. Hooton TM, Levy SB (2002) Confronting the antibiotic resistance crisis: making appropriate therapeutic decisions in community medical practice.http://www.medscape.com/viewprogram/618_pnt

  20. Chen FJ, McDonald LC, Ho M, Lo HJ (2001) Molecular epidemiology of ciprofloxacin reduced susceptible Escherichia coli: a herald for emerging resistance (abstract 2113). Program and abstracts of the 41st Interscience Conference on Antimicrobial Agents and Chemotherapy; 16–19 December 2001, Chicago, Illinois

    Google Scholar 

  21. Karlowsky JA (2002) E. coli resistance to ciprofloxacin growing incrementally each year. Antimicrob Agents Chemother. 46:2540–2545

    Google Scholar 

  22. Raz R, Okev N, Kennes Y, Gilboa A, Lavi I, Bisharat N (2000) Demographic characteristics of patients with community acquired bacteriuria and susceptibility of urinary pathogens to antimicrobials in northern Israel. Israel Med Assoc J 2:426–429

    CAS  Google Scholar 

  23. Raz R, Chazan B, Kennes Y, Colodner E, Rottensterich E, Dan M, Lavi I, Stamm W (2002) Empiric use of trimethoprim-sulfamethoxazole (TMP-SMX) in the treatment of women with uncomplicated urinary tract infections, in a geographical area with a high prevalence of TMP-SMX-resistant uropathogens. Clin Infect Dis 34:1165–1169

    Article  CAS  PubMed  Google Scholar 

  24. Clinical guidelines for the treatment of common infectious diseases in the community. "General Health Services" Health Services, November 2000

  25. Woolf SH, Hutchinson A, Eccles M, Grimshaw J (1999) Potential benefits, limitations, and harms of clinical guidelines. BMJ 318:527–530

    CAS  PubMed  Google Scholar 

  26. Sarrell ME, Madelberg A, Cohen HA, Kahan E (2002) Compliance of primary care doctors with asthma guidelines and related education programs: the employment factor. IMAJ 4:403–406

    PubMed  Google Scholar 

  27. Lomas J, Anderson GM, Domnick-Pierre K, Vayda E, Enkin MW, Hannah WJ (1989) Do practice guidelines guide practice? The effect of a consensus statement on the practice of physicians. N Engl J Med 321:1306–1311

    CAS  PubMed  Google Scholar 

  28. Woolf SH (1993) Practice guidelines: a new reality in medicine, III: impact on patient care. Arch Intern Med 153:2646–2655

    Article  CAS  PubMed  Google Scholar 

  29. Hayward RSA (1997) Clinical practice guidelines on trial. CMAJ 156:1725–1727

    CAS  PubMed  Google Scholar 

  30. Huang ES, Stafford RS (2002) National patterns in the treatment of urinary tract infections in women by ambulatory care physicians. Arch Intern Med 162:41–47

    Article  PubMed  Google Scholar 

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Acknowledgements

The authors wish to thank Mr. Etzion Yatsiv, director of the Leumit Health Fund information system, for his kind cooperation; Mr. Shimon Sister and Dr. Amir Fruman for their assistance in programming the database used to identify the cases; and Mrs. Bella Adler for her guidance in the statistical analysis. The authors also wish to thank Mrs. Gloria Ginzach and Mrs. Marian Propp for their editorial and secretarial assistance. This study is part of Natan R. Kahan's Ph.D. dissertation.

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Authors and Affiliations

  1. Department of Family Medicine, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

    Ernesto Kahan

  2. Hadassah Medical Organization School of Public Health, The Hebrew University of Jerusalem, Jerusalem, Israel

    Natan R. Kahan & David P. Chinitz

  3. Leumit Health Fund, Tel Aviv, Israel

    Natan R. Kahan

  4. Azarim 7/4, 44456, Kfar Saba , Israel

    Ernesto Kahan

Authors
  1. Ernesto Kahan
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  2. Natan R. Kahan
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  3. David P. Chinitz
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Correspondence to Ernesto Kahan.

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Kahan, E., Kahan, N.R. & Chinitz, D.P. Urinary tract infection in women—physician's preferences for treatment and adherence to guidelines: a national drug utilization study in a managed care setting. Eur J Clin Pharmacol 59, 663–668 (2003). https://doi.org/10.1007/s00228-003-0673-4

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  • DOI: https://doi.org/10.1007/s00228-003-0673-4

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