When are empiric antibiotics appropriate for urinary tract infection symptoms?

A recent retrospective case series⁶ evaluated a telephone guideline for the empiric treatment of UTI for 4177 women in a California HMO. UTI criteria were ≤10 days of dysuria; frequency, urgency, pressure, or increased nocturia; or gross hematuria. Women were excluded if they had any one of a variety of contraindications (TABLE 1). Upper tract infection occurred in 21 patients (1.1%) within 60 days of telephone treatment, two thirds of which likely represented treatment failures. This is similar to rates in control groups of other studies. Fourteen women (1.5%) received care for sexually transmitted diseases or other gynecologic conditions, primarily bacterial vaginitis, within 60 days of telephone treatment. Of note, 6% of the cohort were elderly, diabetic, taking glucocorticoids or early in pregnancy and are typically excluded from other studies. This higher-risk group did not have an increased incidence of either sepsis or pyelonephritis.⁶ No increase in adverse outcomes was seen in another study of a telephone treatment protocol.⁷

Several studies^6-8 have noted that telephone treatment protocols increase the use of protocol-recommended antibiotics (eg, generally less expensive agents such as trimethoprim-sulfamethoxazole), which may help limit resistance to fluoroquinolones. However, specific data are not available.

McIssac et al⁹ reviewed a cohort of 231 women presenting to family physicians’ offices with uncomplicated cystitis symptoms. Empiric therapy resulted in approximately 40% of women unnecessarily receiving antibiotics. Treating only women with classic cystitis symptoms and pyuria would have decreased the unnecessary use of antibiotics to 26.2%, but fewer women with confirmed cystitis would have received immediate antibiotics (66.4% vs 91.8%). They derived a clinical decision rule designed to balance false positives and false negatives. It recommends immediate antibiotic treatment if women have ≥2 of 4 signs or symptoms: dysuria, leukocyte esterase (greater than trace), positive nitrites, or blood (greater than trace) on dipstick (LR+=2.29). Otherwise the rule recommends a culture to guide antibiotic therapy. This decision rule would have reduced unnecessary antibiotic use by 27.5% while ensuring that more women with confirmed UTIs received immediate antibiotics (81.3%).

In 1999, Saint et al⁸ estimated savings of $367,000 for 147,000 women enrolled over 1 year after widespread guideline implementation. Two cost-effectiveness studies^10,11 of office treatment concluded that empiric treatment without additional testing is the least costly option in this setting. However, a recent, comprehensive cost-effectiveness study¹¹ concluded that if a patient presents to an office, the marginal cost of performing a pelvic examination and urine culture for women with a negative dipstick was relatively low ($4 to $32 per symptom day avoided).

TABLE 2
Diagnosis of urinary tract infection

Recommendations from others

A 2002 Institute for Clinical Systems Improvement guideline¹² advised offering telephone treatment of uncomplicated UTI for low-risk patients if preferred by both provider and patient.