A recent retrospective case series6 evaluated a telephone guideline for the empiric treatment of UTI for 4177 women in a California HMO. UTI criteria were ≤10 days of dysuria; frequency, urgency, pressure, or increased nocturia; or gross hematuria. Women were excluded if they had any one of a variety of contraindications (TABLE 1). Upper tract infection occurred in 21 patients (1.1%) within 60 days of telephone treatment, two thirds of which likely represented treatment failures. This is similar to rates in control groups of other studies. Fourteen women (1.5%) received care for sexually transmitted diseases or other gynecologic conditions, primarily bacterial vaginitis, within 60 days of telephone treatment. Of note, 6% of the cohort were elderly, diabetic, taking glucocorticoids or early in pregnancy and are typically excluded from other studies. This higher-risk group did not have an increased incidence of either sepsis or pyelonephritis.6 No increase in adverse outcomes was seen in another study of a telephone treatment protocol.7
Several studies6-8 have noted that telephone treatment protocols increase the use of protocol-recommended antibiotics (eg, generally less expensive agents such as trimethoprim-sulfamethoxazole), which may help limit resistance to fluoroquinolones. However, specific data are not available.
McIssac et al9 reviewed a cohort of 231 women presenting to family physicians’ offices with uncomplicated cystitis symptoms. Empiric therapy resulted in approximately 40% of women unnecessarily receiving antibiotics. Treating only women with classic cystitis symptoms and pyuria would have decreased the unnecessary use of antibiotics to 26.2%, but fewer women with confirmed cystitis would have received immediate antibiotics (66.4% vs 91.8%). They derived a clinical decision rule designed to balance false positives and false negatives. It recommends immediate antibiotic treatment if women have ≥2 of 4 signs or symptoms: dysuria, leukocyte esterase (greater than trace), positive nitrites, or blood (greater than trace) on dipstick (LR+=2.29). Otherwise the rule recommends a culture to guide antibiotic therapy. This decision rule would have reduced unnecessary antibiotic use by 27.5% while ensuring that more women with confirmed UTIs received immediate antibiotics (81.3%).
In 1999, Saint et al8 estimated savings of $367,000 for 147,000 women enrolled over 1 year after widespread guideline implementation. Two cost-effectiveness studies10,11 of office treatment concluded that empiric treatment without additional testing is the least costly option in this setting. However, a recent, comprehensive cost-effectiveness study11 concluded that if a patient presents to an office, the marginal cost of performing a pelvic examination and urine culture for women with a negative dipstick was relatively low ($4 to $32 per symptom day avoided).
TABLE 2
Diagnosis of urinary tract infection
| DIAGNOSTIC CRITERIA | LR+ | LR– | SUMMARY LR |
|---|---|---|---|
| Presenting to medical care with possible UTI | 19.0 | ||
| Dysuria | 1.5 | 0.5 | |
| Frequency | 1.8 | 0.6 | |
| Hematuria | 2.0 | 0.9 | |
| Recurrent UTI symptoms for a woman with history of UTI | 4.0 | 0.0 | |
| Vaginal discharge or irritation | 0.2–0.3 | 2.7–3.1 | |
| Dysuria, frequency, and absence of vaginal discharge or irritation | 24.6 | ||
| Dysuria absent, + vaginal discharge | 0.3 | ||
| Dysuria and + vaginal discharge | 0.7 | ||
| + Leukocytes* or + nitrate on urine dipstick analysis | 4.2 | 0.3† | |
| “UTI Rule”‡ | 2.3 | ||
| * Leukocyte greater than trace on dipstick | |||
| † Leukocytes negative and nitrite negative | |||
| ‡ “UTI Rule”—positive if 2 or more present: dysuria,+ leukocytes, + nitrate, + heme (> trace) | |||
| LR, likelihood ratio; UTI, urinary tract infection. | |||
| Adapted from Bent et al, JAMA 2002.1 | |||
Recommendations from others
A 2002 Institute for Clinical Systems Improvement guideline12 advised offering telephone treatment of uncomplicated UTI for low-risk patients if preferred by both provider and patient.