Introduction
Antimicrobial resistance is a well-recognised threat to global health, with the USA alone accounting for 2.8 million antibiotic-resistant infections and 35 000 deaths each year.1 Increasing realisation of the need to minimise this public health threat can be seen in the efforts of regulatory bodies such as the Joint Commission, which recently established requirements for antimicrobial stewardship for ambulatory healthcare organisations, effective at the beginning of 2020.2 The new requirements mandate that such organisations provide resources to practitioners to promote appropriate antibiotic prescribing practices.2
Although most studies of outpatients have focused on implementing antibiotic stewardship for upper respiratory infections,3 4 there is also a high prevalence of inappropriate antibiotic prescribing for urinary tract infections (UTIs) in primary care, including overuse of fluoroquinolones and longer duration of treatment than recommended by guidelines.5–10 A study in France found that only 20% of outpatient UTIs were treated with the guidelines-recommended drug, dose and duration.11 An Irish study found that only 55% of the antibiotic prescriptions for UTI in general practice were appropriate.12 Of 7738 outpatient encounters for UTI in Israel, 91% were treated with a longer duration of antibiotics than recommended by guidelines.13 A recent US study revealed that fluoroquinolones were the most commonly prescribed antibiotics for uncomplicated UTI, comprising up to 49% of prescriptions.6 Inappropriate use of fluoroquinolones is especially concerning because it promotes the emergence and spread of multidrug-resistant Escherichia coli strain sequence type 131.14 In addition, continued overprescribing of fluoroquinolones for uncomplicated cystitis in patients with other treatment options is occurring in the USA5 15 despite two black-box warnings from the US Food and Drug Administration (FDA) for fluoroquinolones due to an association between their use and serious side effects.16–18 In addition, fluoroquinolones were associated with more central nervous system-related and gastrointestinal-related adverse events compared with other types of antimicrobials in a recent meta-analysis.19 Excessive treatment duration for uncomplicated cystitis is another common problem documented internationally.9 13 Current Infectious Diseases Society of America (IDSA) guidelines20 recommend nitrofurantoin for 5 days, trimethoprim–sulfamethoxazole for 3 days and a single dose of fosfomycin as the first-line regimens for uncomplicated cystitis. In our previous study in the same setting, most prescriptions for trimethoprim–sulfamethoxazole, nitrofurantoin and fluoroquinolones had a treatment duration longer than recommended.9
Unlike upper respiratory infections, which typically involve viral infections for which antibiotics are not indicated, a symptomatic UTI merits treatment with antibiotics, as recommended by the IDSA guidelines.20 Thus, the focus in implementing antibiotic stewardship for UTI needs to be optimisation of antibiotic choice and duration, which may present a different cognitive challenge for practitioners than deciding whether a patient needs antibiotics or not. One evidence-based strategy shown to be effective in implementing an antimicrobial stewardship for UTI in acute and long-term care settings is audit and feedback.21–23 Multiple strategies have been employed for implementing stewardship such as feedback to prescribers on antimicrobial consumption and antimicrobial stewardship committee.24 Based on our prior successful experience with audit and feedback in acute and long-term care,21 we implemented a multifaceted antimicrobial stewardship intervention using audit and feedback to improve compliance with acute cystitis guidelines in a family medicine setting (general practice). The objective of our study was to evaluate the impact of a multifaceted stewardship intervention on adherence to the evidence-based practice guidelines on treatment of uncomplicated cystitis in primary care. We hypothesised that our intervention would increase guideline adherence in terms of antibiotic choice and duration of treatment.