Uncomplicated UTIs: A Case for Standardization

Strong data support that women with at least 2 symptoms of UTI (dysuria, urgency, or frequency) and no vaginal discharge have a 90% or greater chance of having a bacterial UTI.
Strong data support that women with at least 2 symptoms of UTI (dysuria, urgency, or frequency) and no vaginal discharge have a 90% or greater chance of having a bacterial UTI.

Google “curse” or “expletive” and you'll find variably vulgar words. From 4-letter profanities to 12+ letter obscenities, these terms assert strongly negative or even hostile emotions. What won't appear on such lists are words like “guidelines,” “standards,” or “checklists,” even though they can be equally dispiriting to many well-intentioned, hard-working clinicians who equate such terms with excessive oversight or “cookbook medicine.”

Physicians recognize the need for standards and process improvement in medicine. Yet the complexities of individual patient care seem far removed from manufacturing and other industries necessitating rigorously controlled standards. Indeed, standardization implies loss of control. Most providers understand that the benefits of variations in care are best measured only after appropriate and rational standards are put in place, particularly for the treatment of common ailments.

Outpatient treatment of uncomplicated urinary tract infections (UTIs) is common. They account for more than 8 million visits to doctors' offices, emergency departments, and urgent care facilities annually. Practicing physicians recognize that evaluation, antibiotic choice, duration of therapy, and follow-up of UTIs vary significantly. 

In a recently published review of 27 randomized controlled trials, 6 systematic reviews, and 11 observational studies involving more than 250,000 patients, Grigoryan and colleagues outline common sense processes and standards for management for uncomplicated UTIs.

Strong data support that women with at least 2 symptoms of UTI (dysuria, urgency, or frequency) and no vaginal discharge have a 90% or greater chance of having a bacterial UTI. Given the high pre-test probability, additional testing (urine dipstick and culture) appear to provide no additional benefit. Thus, an office visit without culture, telephone management, or patient-initiated therapy is acceptable for uncomplicated UTIs in women. Treatment with single dose fosfomycin (3 g), nitrofurantoin (100 mg po bid × 5 days) or trimethoprim-sulfamethoxazole (1 DS bid × 3 days) is equivalent to alternative and overused therapies (e.g., ciprofloxacin 250 mg bid × 3 d) and better than a beta-lactam antibiotic (e.g., amoxicillin-clavulanate).

Algorithmic care can be easily and broadly applied to most practices. Health system, data-driven, community-centric, physician-led standardized approaches to common ailments represent the lowest-hanging fruit toward delivering better care. Standardizing when it's easy allows you to standardize when it's hard. Building a provider culture around simple standards is anything but profane.

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