Sustainable strategies for appropriate urinary tract infection management

Urinary tract infections (UTIs) belong to the most common infectious diseases worldwide and are often treated with antibiotics. However, not all patients with positive urine tests require antibiotic treatment. Particularly, patients with asymptomatic bacteriuria (ASB), a positive urine culture without symptoms of a UTI, are often inappropriately treated, partly due to frequent urine testing across various healthcare settings. This inappropriate treatment is an example of low-value care. De-implementation strategies target reducing low-value care. We conducted a de-implementation strategy consisting of education and feedback about ASB to reduce its overtreatment in emergency departments. Although the percentage of patients with ASB who were overtreated with antibiotics was not significantly reduced, the number of urine tests ordered was lower after the implementation of the strategy.
Further, we evaluated the long-term effects of a de-implementation strategy that was used to reduce the inappropriate use of catheters, another example of low-value care. We showed that the effect of de-implementation can be sustained for at least five years.
In primary care, healthy women with uncomplicated UTIs (i.e., cystitis) can recover spontaneously without antibiotics. However, most women receive antibiotic treatment, even though general practitioners are encouraged to facilitate conversations with women about both antibiotic and non-antibiotic treatment options. We used qualitative studies to investigate the management of urinary tract infections in primary care and identified several barriers and facilitators influencing the decision-making process.
Overall, individual and system-wide approaches are necessary to decrease low value care in the diagnostic and therapeutic management of patients with UTIs and ASB.