Rates of Guideline Concordance Among Empiric Urinary Tract Infection (UTI) Treatment for Women Presenting to the Emergency Department (ED)

INTRODUCTION: Limitations exist to the accuracy of urinalysis or point-of-care testing commonly performed in the ED; however, empiric antibiotic treatment is routinely provided. With increasing rates of antibiotic resistance and risk of antibiotic side exposures, guideline-concordant antibiotic selection is increasingly important for appropriate management of UTIs and antibiotic stewardship. OBJECTIVE: Evaluate the rate of guideline-concordant empiric antibiotic selection or overtreatment (prescription with resultant negative culture) for women treated for an uncomplicated UTI in the ED. METHODS: This was a retrospective cohort of women 18 years or older who were treated outpatient for an acute uncomplicated UTI at one of 13 ED sites within a single tertiary medical center between October 2023 and April 2024. All patients had a urine culture sent and received an antibiotic prescription at the time of index ED visit. Patients who were admitted to the hospital, had catheterization or other urinary diversion, or were pregnant or postpartum at time of an ED visit were excluded. Baseline and presenting cohort characteristics, including age, ED location, chief complaint, comorbidities, antibiotic allergy history, ED urinalysis, and history of prior urine studies over the last 12 months, were collected. Descriptive statistics were performed using t-test, chi-squared test, and univariate logistic regression. Characteristics significantly associated with guideline-concordant care from univariate analysis were included in a multivariate logistic regression. RESULTS: We identified 3,887 index ED visits over the 6-month period. In 1,416 (36.4%) visits, guideline-concordant treatment for UTI was provided. A positive urine culture was only found for 32.1% of visits. A non-urinary chief complaint was recorded in 76.8% of women receiving guideline-concordant treatment compared to 82.1% that received guideline-discordant treatment (p<0.001). Women receiving guideline-concordant care more often had an antibiotic allergy history (p<0.001). The most commonly prescribed guideline-concordant antibiotics were sulfamethoxazole-trimethoprim (34.7%), nitrofurantoin (32.8%), and cephalexin (23.9%). The most commonly prescribed guideline-discordant antibiotics were cephalexin (62.5%), penicillins (10.4%), and ciprofloxacin (5.7%). In multivariable logistic regression for guideline-concordant antibiotic treatment, rural ED location [aOR 0.69 (95% CI 0.52–0.92)], increasing age [per year aOR 0.98 (95% CI 0.98 – 0.99)], and prior urine culture within the last 12 months [aOR 0.89 (95% CI 0.83–0.96)] were associated with a lower likelihood guideline-concordant treatment. Pyelonephritis diagnosis [aOR 1.56 (95% CI 1.09–2.20)], prior urinalysis within the last 12 months [aOR 1.06 (95% CI 1.01–1.10)], and antibiotic allergy history were positively associated with guideline-concordant treatment. Specifically for antibiotic allergy history, the following adjusted odds ratios were noted: sulfamethoxazole-trimethoprim [aOR 14.65 (95% CI 10.32–20.81)], nitrofurantoin [aOR 10.66 (95% CI 4.16–27.23)], cephalosporins [aOR 3.86 (95% CI 2.13–6.97)], and penicillin [aOR 1.78 (95% CI 1.33–2.39)]. CONCLUSIONS: Guideline-concordant empiric antibiotic treatment for UTI was provided in only one third of ED discharges with a diagnosis of UTI and fewer than one third of visits diagnosed and treated for a UTI had a positive urine culture. Strategies to improve guideline adherence are necessary to improve diagnosis of UTI and minimize overtreatment.