• Vol. 53 No. 7, 456–459
  • 24 July 2024

Gaps in primary care management of urinary tract infections in Singapore

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Dear Editor,

Urinary tract infection (UTI) is a common presentation in primary care, but gaps of care have not been well established in Singapore. UTIs are one of the most common bacterial infections worldwide,1 constituting around 1% of all ambulatory clinic visits.2 The healthcare burden of UTIs remains highly significant, with billions per year lost in societal costs (e.g. healthcare costs and time missed from work) alone.2 In Singapore, genitourinary infections were the second most common group of conditions for which antibiotics were prescribed in 2021.3

Appropriate antibiotic prescribing is key to prevent resistance. Although international guidelines recommend clinical diagnosis of UTI based on typical symptoms of dysuria, urgency, frequency and the absence of vaginal discharge,4 in Singapore, only 26% of UTIs were diagnosed clinically without the aid of urinary investigations.5 With the potential for significant number of care gaps, we conducted a study to examine these gaps to improve practice, management and patient safety.

Random sampling of 280 adult patients with visit diagnosis of UTI from July to December 2021 was performed, with 40 patients selected from each of the 7 National University Polyclinics in Singapore. Case notes review was conducted by trained primary care physicians to identify and classify gaps in history, documentation, examination, investigations, diagnosis, labelling, management, follow-up and antibiotic prescriptions.

To determine antibiotic appropriateness, we reviewed international guidelines for acute uncomplicated cystitis, including the European Association of Urology (2022),6 National Institute for Health and Care Excellence Guidelines (2018)7 and Infectious Diseases Society of America Guidelines (2010).8 This was paired with local antibiograms, expert opinions and published recommendations in Singapore. The list of antibiotics and doses considered appropriate were:

  • Amoxicillin/clavulanate 625 mg 2 to 3 times a day (BD-TDS) for 3 to 7 days
  • Cephalexin 500 mg 2 to 4 times a day (BD-QDS) for 5 to 7 days (while several guidelines recommend higher dosage, i.e. 500 to 1000 mg BD-QDS, newer studies suggest equal efficacy in twice-daily versus 4-times-daily dose)9
  • Co-trimoxazole 2 tablets 2 times a day (BD) for 3 days
  • Nitrofurantoin 50 to 100 mg 4 times a day (QDS) for 3 to 7 days

Statistical analyses were performed with IBM SPSS Statistics version 28.0 (IBM Corp, Armonk, NY, US). Descriptive statistics was used to showcase prevalence data, chi-square test to compare relationship between categorical variables and fixed effects Poisson regression to analyse factors affecting number of gaps per UTI visit.

A total of 280 patients were reviewed, with a mean age of 50.7 years (Table 1). Majority were female, largely premenopausal. Among patients with uncomplicated UTIs, 18.2% were recurrent. The most common cause of complicated UTIs were in males (69.5%). There were 12 patients (4.3%) who were inaccurately coded as UTI; 85% of patients had urine tests performed to guide diagnosis of UTI. The most common antibiotic prescribed is amoxicillin-clavulanate (50%). There were 41.4% of patients who had no gaps of care during their visit for UTI, with a mean number of gaps per patient at 0.81. The greatest number of gaps were present in history and documentation (31.6%). Significant number of gaps were also found in antibiotic prescriptions (22.4%), of which excessive antibiotic duration formed the majority (45.1%). 

Table 1. Characteristics of patients with visit diagnoses labelled as urinary tract infections (UTIs).

Study characteristics Total (n=280)
Mean age, (SD), years 50.7 (18.8)
Sex, no. (%)
Female 239 (85.4)
    Pre-menopausal 133 (55.6)
    Post-menopausal 106 (44.4)
Male 41 (14.6)
UTI type
Uncomplicated UTIs 207 (73.9)
    Episodic UTI 171 (82.6)
    Recurrent UTI 36 (17.4)
Complicated UTIs 59 (21.1)
    Male UTIs 40 (67.8)
    Suspected pyelonephritis 8 (13.6)
    Known urethral or bladder abnormalities 4 (6.8)
    Partially treated UTI 4 (6.8)
    Previous nephrolithiasis 3 (5.1)
Not UTIs 14 (5.0)
Urine microscopy utilisation rate in UTI diagnosis, no. (%) 238 (85.0)
Antibiotic prescribed
Amoxicillin-clavulanate 140 (50.0)
Nitrofurantoin 63 (22.5)
Ciprofloxacin 31 (11.1)
Co-trimoxazole 22 (7.9)
Cephalexin 14 (5.0)
No antibiotic prescribed 10 (3.6)
Mean no. of gaps per patient (SD) 0.81 (0.86)
No. of gaps per patient, no. (%) n=228
0 116 (41.4)
1 114 (40.7)
2 40 (14.3)
3 6 (2.1)
4 4 (1.4)
Distribution of gaps, no. (%)a
Gaps in history and documentation 72 (31.6)
    Last menstrual period not documented 68 (94.4)
Gaps in examination 1 (0.4)
Gaps in investigation 45 (19.7)
Urine culture not sent in complicated UTIs 27 (60.0)
Urine culture sent in uncomplicated UTIs 15 (33.3)
Gaps in diagnosis 22 (9.6)
Urine microscopy clear, still treated with antibiotics 6 (27.3)
Gaps in labelling 7 (3.1)
Gaps in management/follow-up 30 (13.2)
Male UTI not referred to urologist 13 (43.3)
Gaps in antibiotic prescription 51 (22.4)
Antibiotic prescribed for excessive duration 23 (45.1)
Ciprofloxacin prescribed for uncomplicated UTIs 13 (25.5)
Nitrofurantoin prescribed for elderly 11 (21.6)

SD: standard deviation
a Total number of gaps may not tally as each patient encounter may have multiple number of gaps.

Patients who presented with uncomplicated UTIs were found to be significantly associated with increased gaps in history and documentation (P<0.001). Patients with uncomplicated UTIs were more likely to have gaps in history or documentation (odds ratio [OR] 4.32, 95% CI 1.88–9.92).

For our Poisson regression, the variance for number of gaps was 0.74. The goodness-of-fit test value divided by degree of freedom was 0.91 and the omnibus test was P<0.05. After adjusting for sex and clinic characteristics, patients with complicated UTIs or non-UTIs had a significantly increased incidence of care gaps (risk ratio [RR] 2.20, 95% CI 1.57–3.09), compared to those with uncomplicated UTIs. The incidence rate of gaps in care decreased by 1.6% (RR 0.984, 95% CI 0.977–0.992) for each 1-year increase in age.

This study had 2 main findings. First, history constituted majority of the gaps, especially among young female patients with uncomplicated UTIs, pertaining to documentation of their last menstrual period. This highlighted a potential antibiotic safety issue, as ciprofloxacin and co-trimoxazole are not recommended for use in pregnant women. Secondly, patients presenting with complicated UTIs or non-UTIs had more frequent care gaps.

Our study identified significant lapse in antibiotics prescribed for UTI, accounting for more than one fifth of all lapses identified. Dosing errors were mostly mitigated locally due to electronic dosing recommendations. However, antibiotic duration was left to the discretion of physicians. A fixed, pre-programmed medication order including recommended dose, frequency and duration will reduce prescription gaps and improve medication safety.

Ciprofloxacin prescription for uncomplicated UTIs was also an issue. In Singapore, increasing ciprofloxacin resistance has been found in urinary Escherichia coli, which translates to increased treatment failure rate in uncomplicated UTIs.5 Ciprofloxacin was also found to be inappropriately used for the treatment of multiple outpatient infections, contributing to the development of multidrug resistant organisms. Guidelines can mitigate its usage, which was also listed as an antibiotic in the WATCH group (antibiotics that should be monitored by health authorities to prevent spread and further emergence of antibiotic resistance), according to the World Health Organization Access, Watch, and Reserve classification.

Our study also found that patients with complicated UTIs or non-UTIs had more frequent gaps in care. This echoed what was found in other settings internationally, where errors occurred in special groups of patients with asymptomatic bacteriuria, such as the elderly; patients with diabetes, urinary catheter in-situ, urinary tract dysfunction; and patients after transplantation. While major guidelines adequately covered diagnosis and management of uncomplicated UTIs, management of complicated UTIs and non-UTIs were less emphasised. Therefore, it would be prudent to continue education of physicians in this area to bridge these gaps.

We acknowledge that clinical practices are constantly evolving and geographically dependent, hence limiting the generalisability of this study probably to the primary care context in Singapore. Future studies with larger sample size could be replicated across all 3 public primary care institutions to reduce risk of type 1 error.

With the Singapore guideline for uncomplicated UTIs in place since November 2023,10 our attention can turn to addressing complicated UTIs and masquerades. By doing so, we can improve physicians’ confidence in managing UTIs, reduce inappropriate antibiotic use, and deliver high-quality and safe care to all patients.

Declaration

All authors have no affiliations or financial involvement with any commercial organisation with a direct financial interest in the subject or materials discussed in the manuscript.

Funding

This research is supported by the Singapore Ministry of Health’s National Medical Research Council under its Centre Grant Programme (MOH-001010-00).

Institutional Review Board Approval

The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Institutional Review Board of the National Healthcare Group (2023/00275) on 1 June 2023.

Acknowledgements

We would like to acknowledge the expert opinions of Professor Hsu Li Yang (Vice Dean Global Health, Saw Swee Hock School of Public Health, National University of Singapore), Professor Paul Ananth Tambyah (Senior Consultant, Division of Infectious Diseases, National University Hospital) and Dr Louisa Sun Jin (Consultant, Division of Infectious Diseases, Department of Medicine, Alexandra Hospital). We would also like to thank Ms Low Si Hui (Family Medicine Development, National University Polyclinics) for assisting in data visualisation, Dr Victor Lee, Dr Selvamani D/O Balasubramaniam, Dr Davamani D/O Diraviyam, Dr Shipra Lather, Dr Tan Xin Yu and Dr Joanna Ooi (National University Polyclinics) for study conduct and data review.

Correspondence: Dr Sky Wei Chee Koh, Family Medicine Department, National University Polyclinics, Corporate Office, 1 Jurong East Street 21, Singapore 609606. Email: [email protected]

This article was first published online on 24 July 2024 at annals.edu.sg.


REFERENCES

  1. Lecky DM, Howdle J, Butler CC, et al. Optimising management of UTIs in primary care: a qualitative study of patient and GP perspectives to inform the development of an evidence-based, shared decision-making resource. Br J Gen Pract 2020;70:e330-8.
  2. Flores-Mireles AL, Walker JN, Caparon M, et al. Urinary tract infections: epidemiology, mechanisms of infection and treatment options. Nat Rev Microbiol 2015;13:269-84.
  3. Koh SWC, Lee VME, Low SH, et al. Prescribing antibiotics in public primary care clinics in Singapore: a retrospective cohort study. Antibiotics (Basel) 2023;12:762.
  4. Chu CM, Lowder JL. Diagnosis and treatment of urinary tract infections across age groups. Am J Obstet Gynecol 2018;219:40-51.
  5. Koh SWC, Ng TSM, Loh VWK, et al. Antibiotic treatment failure of uncomplicated urinary tract infections in primary care. Antimicrob Resist Infect Control 2023;12:73.
  6. Bonita G, Bartoletti R, Bruyere F, et al. EAU Guidelines on Urological Infections. EAU Guidelines. Presented at EAU Annual Congress Milan, Italy, 2023.
  7. National Institute for Health and Care Excellence. Urinary tract infection (lower): antimicrobial prescribing. NICE guideline [NG109]. Published 31 October 2018. www.nice.org.uk/guidance/ng109. Accessed 30 September 2023.
  8. Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis 2011;52:e103-20.
  9. Yetsko A, Draper HM, Eid K, et al. Two times versus four times daily cephalexin dosing for the treatment of uncomplicated urinary tract infections in females. Open Forum Infect Dis 2023;10:ofad430.
  10. Agency for Care Effectiveness, Ministry of Health, Singapore. Urinary tract infections appropriate diagnosis and antibiotic use for uncomplicated cystitis and pyelonephritis. Published 17 November 2023, updated 8 December 2023. https://www.ace-hta.gov.sg/healthcare-professionals/ace-clinical-guidances-(acgs)/details/urinary-tract-infections-appropriate-diagnosis-and-antibiotic-use-for-uncomplicated-cystitis-and-pyelonephritis. Accessed 4 March 2024.