Multimodal intervention reduces second-line antibiotic prescriptions for UTI

A multimodal intervention applied in general practice results in a significant decrease in antibiotic prescribing and an increase in guideline adherence among women with uncomplicated urinary tract infection (UTI), a study has shown.

“If implemented on a larger scale, our results are likely to have a sustainable positive impact on antibiotic stewardship programs for uncomplicated UTI in primary care,” the investigators said.

General practitioners (GPs) from 128 randomly assigned practices in Germany participated in this randomized, controlled trial. Data were obtained between 1 April 2021 and 31 March 2022.

The multimodal intervention consisted of guideline recommendations for GPs and patients, provision of regional data for antibiotic resistance, and quarterly feedback, which included individual first- and second-line proportions of antibiotic prescribing, benchmarking with regional or supra-regional practices, and telephone counseling. Control participants received no information on the intervention.

A total of 110 practices with full datasets identified 10,323 patients over 15 months. After 12 months, second-line antibiotic prescription declined in the intervention group compared with the control group (mean proportion, 0.19 vs 0.35). The mean difference after adjusting for preintervention proportions was ‒0.13 (95 percent confidence interval [CI], ‒0.21 to ‒0.06; p<0.001). [BMJ 2023;383:e076305]

Overall proportion of antibiotic prescriptions for UTI over 12 months was 0.74 and 0.80 in the intervention and control groups, respectively. The mean difference was ‒0.08 (95 percent CI, ‒0.15 to ‒0.02; p<0.029).

Complications, such as pyelonephritis, admission to hospital, or fever, did not significantly differ in number between the two groups.

“Despite a lower proportion of antibiotic prescriptions in the intervention group, complication rates within the 12-month period were similar in both groups,” the investigators said. “The rate of admissions to hospital in our study (0.2 percent) was identical to the results of a nationwide, register cohort study in Sweden including 752,289 women with acute uncomplicated UTIs.” [Antibiotics (Basel) 2022;11:1695]

Recurrent UTI

In exploratory analysis, the rates of recurrent UTI differed between the two groups (12 percent [intervention] vs 17 percent [control], respectively; p<0.001). Greater use of second-line antibiotics contributed to higher resistance rates of E coli and treatment failure. [BMC Infect Dis 2015;15:545]

“Since, in our study, the resistance rates for recurrent UTI were in favour of first-line antibiotics due to their low resistance rates, this could explain the reduced rates of recurrent infections in the intervention group,” the investigators said. “However, we cannot rule out a documentation bias because the time between training for and conducting data extraction for recurrent UTI was different in the two groups.”

Implications

The findings of the current study demonstrated the effectiveness of the multifaceted intervention. The investigators believed that all components could be implemented in countries where the digitalization level allowed automated data extraction and feedback was possible.

“In Germany, implementing of the materials is possible for example within the continuous postgraduate medical education or work in quality circles,” the investigators said. “We do not expect relevant barriers in implementing resistance data, but they have to be collected and presented at regional level because they are affected by different antibiotic recommendations or policies.”