What are reasonable quality indicators (for internal quality improvement) for empirical antimicrobial treatment in patients with a UTI?
Reasonable process quality indicators for empirical antibiotic therapy in patients with UTI to use in the Internal Medicine and Urology department are:
- Performance of urine culture.
- Prescription of treatment in accordance with guidelines.
- Tailoring of treatment on the basis of culture results.
- Switching to oral treatment when possible.
An additional four indicators to use only in the Internal Medicine department are:
- Treatment durations must follow the guidelines for the different patient groups.
- Prescription of treatment for men in accordance with guidelines.
- Replacement of catheters in patients with UTI.
- Adaptation of the dosage on the basis of renal function.
It is recommended by the current Guideline committee that these process indicators may be used as internal Quality Improvement indicators in local QI projects. It is not recommended to use these indicators as performance indicators to compare hospitals.
All the above-mentioned QIs can be developed again from the present revision of this guideline, with the exception of “Administration of treatment for at least 10 days”. Based on the latest available study results, the updated guideline recommendations concerning treatment durations are:
- Women with acute uncomplicated pyelonephritis should be treated for 7 days when treated with ciprofloxacin.
- Women with acute uncomplicated pyelonephritis should be treated for 10-14 days when treated with TMP-SMX or a beta-lactam.
- Women with acute complicated pyelonephritis or other complicated UTIs should be treated for 10-14 days.
- Men with complicated UTIs should be treated for 14 days.
Therefore, the Guideline committee decided to change the treatment duration indicator to read: Treatment duration should follow the guideline recommendations for the different patient groups.
Furthermore, because interpretation of the results of the indicator “Selective use of fluoroquinolones” was very difficult, this indicator is no longer recommended (Spoorenberg et al. abstract IDSA 2011).
Recent evaluation of these QIs among 1,964 patients with a complicated UTI in 19 Dutch hospitals revealed that the quality of antibiotic treatment showed a wide variation between departments and considerable room for improvement. Median indicator performance ranged from 26-77%, with the lowest median performance on the indicator “Prescribe treatment for men in accordance with guidelines” (26%, range between departments 5-51%), and the highest on the indicator “Perform a urine culture” (77%, range between departments 28-93%). For other indicators like “Tailor treatment according to culture results” and “Switch from i.v. to oral therapy after 48-72 hours” there was also a wide inter-departmental range (Spoorenberg et al. abstract IDSA 2011).
Another important consideration is that QIs are increasingly used for perspectives other than internal quality improvement alone. External comparison (QIs used as performance indicators) is commonly used to compare hospitals and physicians, as minimal control measures for the Dutch Healthcare Inspectorate, but also as tools for contract negotiations between hospitals and healthcare insurers, and as transparency measures for patient and public.
The current Guideline committee is of the opinion that the above-mentioned process indicators may be used as internal Quality Improvement indicators used in local QI projects, but they were not designed as performance indicators allowing a valid comparison between hospitals.
This guideline does not include individual introductions to each module. A general introduction can be found in the attachments under the heading 'related'.
Based on the 2006 SWAB guideline for the treatment of complicated UTIs, a set of valid quality indicators was developed: Four indicators performed satisfactorily both in the Internal medicine and Urology departments and an additional five indicators performed satisfactorily only in the Internal Medicine department [(172) C].
Quality indicators (QIs) must comply with high quality standards and should be constructed in a careful and transparent manner (171). Optimally, they should measure the quality in a valid and reliable manner with little inter- and intra-observer variability so that they are suitable for comparison between professionals, practices, and institutions (171). However, it should be emphasized that many of the current QIs have been constructed based on relatively weak evidence and, rather, represent current best practices.
Based on the 2006 SWAB guideline for the treatment of complicated UTIs, in 2008 we developed a set of valid QIs for the antibiotic treatment of patients with UTI (172). A multidisciplinary panel of 13 experts reviewed and prioritized recommendations extracted from this evidence-based national guideline. The content validity was assessed in 2 consecutive rounds with an in-between discussion meeting. Next, we tested the feasibility, interobserver reliability, opportunity for improvement, and case-mix stability of the potential indicators for a dataset of 341 inpatients and outpatients with complicated UTIs who were treated at the urology or internal medicine departments at 4 hospitals. The panel selected and prioritized 13 indicators.
Four indicators performed satisfactorily both in the Internal medicine and Urology departments:
1 Performance of urine culture
2 Prescription of treatment in accordance with guidelines
3 Tailoring of treatment on the basis of culture results
4 Switch to oral treatment when possible ;
An additional five indicators performed satisfactorily only in the Internal Medicine department, mainly because not enough patients could be included in the Urology department:
5 Selective use of fluoroquinolones
6 Treatment duration at least 10 days
7 Prescription of treatment for men in accordance with guidelines
8 Replacement of catheters in patients with UTI
9 Adaptation of the dosage on the basis of renal function.
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This guideline does not include evidence tables.
Authorization date and validity
Last review : 01-03-2013
Last authorization : 01-03-2013
This guideline was developed and approved by representatives of the professional medical societies, mentioned in the introduction and methods sections and therefore represents the current professional standard in 2013. The guideline contains general recommendations. It is possible that, in individual cases, these recommendations do not apply. Applicability of the guideline in clinical practice resorts to the responsibility of every individual practitioner. Facts or circumstances may occur, in which deviation of the guideline is justified, in order to provide optimal quality of care for the patient.
Initiative and authorization
Development of this guideline was supported and financed by the SKMS (Kwaliteitsgelden Medisch Specialisten).
Scope and target group
The objective of these guidelines is to update clinicians with regard to important advances and controversies in the antibiotic treatment of patients with complicated urinary tract infections (UTIs).
The guidelines described here cover the empirical antimicrobial therapy of adult patients (for this guideline 12 years or older) with a complicated UTI admitted to a hospital (emergency room or ward) in the Netherlands. Uncomplicated UTIs are treated predominantly by the general practitioner. For the relevant guidelines, see the recently updated Standard for Urinary Tract Infections of the Dutch Society of General Practitioners (NHG). We have tried to adhere to this standard insofar as possible. Urethritis and epididymitis are not included in this guideline.
The Guidelines give a general therapy advice for all UTI with systemic symptoms because, at first presentation of a patient, it is not always possible to differentiate between an acute prostatitis, pyelonephritis or urosepsis. In addition, this differentiation has no consequences for the choice of empirical antimicrobial therapy. Apart from these general guidelines, we give specific advice for certain groups of patients separately.
Preparation of the guideline text was carried out by a multidisciplinary committee consisting of experts, delegated from the professional societies for infectious diseases (VIZ), medical microbiology (NVMM), hospital pharmacists (NVZA), urology (NVU), gynaecology (NVO), nephrology (NFN) and general practice (NHG). After consultation with the members of these professional societies, the definitive guideline was drawn up by the delegates and approved by the board of SWAB.
- Dr. S.E. Geerlings (coordinator, SWAB), Internal Medicine/Infectious Diseases specialist, Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Center, Amsterdam
- Dr. C. van Nieuwkoop (VIZ, NIV), Internal Medicine, Emergency Medicine and Infectious Diseases specialist, Department of Internal Medicine, Hagaziekenhuis, the Hague
- E. van Haarst (NVU), Urologist, Department of Urology, St. Lucas Andreas Hospital, Amsterdam
- Dr. M. van Buren (NFN), Internal Medicine and Nephrology specialist, Department of Internal Medicine, Hagaziekenhuis, the Hague
- Dr. B.J. Knottnerus (NHG), General Practitioner, Department General Practice, Academic Medical Center, Amsterdam
- Dr. E. E. Stobberingh (NVMM), Medical microbiologist, Lab Medical Microbiology, Maastricht Univerisity Medical Center, Maastricht
- Prof. dr. C.J. de Groot (NVOG), Gynaecologist, Department of Obstetrics and Gynaecology, Vrije Universiteit Medical Center, Amsterdam
- Prof. dr. J.M. Prins (SWAB), Internal Medicine/Infectious Diseases specialist, Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Center, Amsterdam
The Guideline committee would also like to thank Frederique Bemelman (nephrologist) for her comments on the chapter about renal transplantation and Albert Vollaard (infectious disease specialist) for his comments on the subchapter about methenamine.
Declaration of interest
The SWAB employs strict guidelines with regard to potential conflicts of interests as described in the SWAB Format for Guideline Development (www.swab.nl). Members of the preparatory committee reported the following potential conflicts of interest:
SE Geerlings: for the RCTs mentioned in the reference numbers 84 en 168 (Beerepoot et al.): Ref 84: Cranberry capsules and placebo capsules for this trial were delivered by Springfield Nutraceuticals, Oud Beijerland, The Netherlands. Ref 168: Chr Hansen A/S, Denmark has the patents for Lactobacillus rhamnosus GR-1 and Lactobacillus reuteri RC-14 and donated the placebo capsules for this trial.
E v Haarst: has received speaker fees on a national urological symposium from GlaxoSmithKline, the manufacturer of amoxicillin-clavulanic acid.
Other authors: no potential conflicts of interest declared.
This guideline does not include patient involvement.
Method of development
This guideline does not include an implementation strategy.
Methods and proces
This guideline was drawn up according to the recommendations for evidence-based development of guidelines (6), (Evidence-Based Richtlijn-Ontwikkeling (EBRO) and Appraisal of Guidelines Research and Evaluation (AGREE), www.agreecollaboration.org). The guidelines are derived from a review of literature based on the 9 key questions concerning the treatment of UTI. Studies were assigned a degree of evidential value according to the handbook of the Dutch Institute for Healthcare Improvement (Centraal Begeleidingsorgaan/Kwaliteitsinstituut voor de gezondheidszorg, CBO) (CBO. Evidence-based Richtlijnontwikkeling, handleiding voor werkgroepleden. Utrecht: CBO; 2007). Conclusions were drawn, completed with the specific level of evidence, according to the grading system adopted by SWAB (Table 1 and 2). The only exception concerns Nethmap, an annual report from which the resistance surveillance data were used. The Guideline committee cannot give Nethmap a level of evidence and decided to use an asterix (*), but is of the opinion that the results can be given substantial weight, since the surveillance data described in Nethmap cover 30% of the Dutch population. Subsequently, specific recommendations were formulated.
In order to develop recommendations for the optimal treatment of UTI, the literature was searched for the key questions. For each question a literature search was performed in the PubMed database (January 1966 to January 2012) as well as in the Cochrane Register of Controlled Trials (CENTRAL). For resistance surveillance data NethMap 2011 was used, and for the interpretation of susceptibility test results, in addition, reports of the European Committee on Antimicrobial Susceptibility Testing (EUCAST) were used. When scientific verification could not be found, the guideline text was formulated on the basis of the opinions and experiences of the members of the Guideline committee.
Searches are available upon request. Please contact the Richtlijnendatabase.