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Uncomplicated UTI Care in the ED
When Care Gets Complicated: Uncomplicated UTI Management in Acute Care Settings

Released: November 16, 2023

Lilly C. Lee
Lilly C. Lee, MD, SM, FACEP, FAAEM
Activity Information

Activity

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Key Takeaways
  • Lack of information and lack of follow-up are major challenges of seeing patients with uUTI in the ED.
  • HCPs should use local resources to help facilitate access to medications for underresourced patients, including prescribing generic therapies whenever possible and being knowledgeable on which pharmacies offer low-cost medications.

In my emergency department (ED), we see approximately 245 patients per day, on average, and urinary tract infection (UTI) is the seventh most common complaint. We never want to discourage referrals, but it can be very challenging for healthcare professionals (HCPs) to manage uncomplicated UTIs (uUTIs) in acute care settings with multiple patients of varying acuity competing for limited resources.

Challenges of uUTI in the ED
A major challenge in the ED is treating patients with limited information as we usually do not have established relationships with patients. Limited information can make it more difficult to differentiate between a complicated UTI and a uUTI, which can present with similar symptoms and range in severity.

We try to gather as much information as possible from the patient and medical record, but important information may still be lacking in this setting. For these reasons, it is key to have refined diagnostic and therapeutic protocols and tools to use. For example, we can use an updated local antibiogram to inform empiric antimicrobial selection based on local resistance patterns.

In a similar vein, patient follow-up is also a challenge. For patients who do have a primary care provider (PCP), follow-up is challenging because communication between the ED and PCP is still lacking. However, patients who come to the ED are often underresourced and may not be able to obtain follow-up care from another site.

Another challenge of caring for uninsured or underinsured populations is they often come in already sicker than they ought to be because of delayed care or incomplete treatment.

Local Resources to Bridge the Gap for Under/Uninsured Patients
For the underinsured and the uninsured, access to medication is a huge issue. Even if an effective and safe antibiotic is prescribed, the patient may not be able to access or afford it, especially if the prescription is for a brand name rather than a generic.

To address this in my practice, we educate HCPs about prescribing generic medications. We constantly review pharmacies, including grocery store pharmacies, to find facilities that provide low-cost antibiotics. When prescribing medications for underresourced patients, we consult that list, compare it with our antibiogram, and strive to prescribe medications that are both appropriate and affordable.

Another option we have is a safety-net medication program. With this program, the hospital administration can decide, case by case, to give people their medications for free. The idea is that if patients cannot obtain their prescriptions, they will return even sicker, which is bad for patient care and costly to the healthcare system.

However, even with these practices, we need to know when patients are struggling to be able to help them. So, we also teach HCPs to ask the right questions, in a sensitive and empathetic manner. For example, for patients with a lack of access or a history of nonadherence, providing a single-dose antibiotic regimen may be a great option.

In all, the key is not just to provide resources for patients, but also to educate our HCPs on how to communicate with, and advocate for, our patients.

Best Practices in Multidisciplinary Care
As I described earlier, one of the challenges of working in the ED is working with limited information. In the past, it was standard practice at my hospital to treat patients empirically and discharge them. However, with no collaboration and no patient follow-up, we had no idea whether we were appropriately prescribing the right medication for the right organism. We need better antimicrobial and diagnostic stewardship.

To address this problem, we formed a multidisciplinary team. We worked with the lab and the pathologist to develop urine analysis criteria that, if met, would automatically reflex to a urine culture. Prior to this protocol, the lack of standardization meant that urine cultures were sometimes ordered unnecessarily or omitted when they should have been ordered.

We also worked closely with our team, including infectious disease specialists and pharmacists, to develop an ED-specific antibiogram. This enabled us to be more confident that the appropriate empiric antibiotics had been prescribed. Now, if a culture is ordered, a pharmacist reviews the results and decides if a change in therapy is needed. Through the protocol, they can choose the best course of action: to continue therapy, adjust therapy, or escalate to a physician to review. 

Finally, a quality assurance nurse conducts follow-up phone calls. This additional follow-up is not something that many EDs do, but it can be critical for determining if the patient has received appropriate care. As nurses are talking to the patients, they can determine if the patients should be advised to come back or if they might need an adjustment to their medications. Ideally, we are then able to communicate these results back to the patients’ PCP if they have one. Sharing these data can help PCPs prescribe antibiotics more appropriately for patients who present with symptoms of UTI.

Another benefit of this program is how it facilitates communication within a healthcare system. Many of us now work within a single healthcare system, allowing patients to go to clinics and PCPs affiliated with the system. For example, a hospitalist may eventually end up admitting the patient for a more severe UTI, so having this information can guide them in prescribing care until they get the final cultures back.

In addition to guiding future care of the patient, this system provides HCPs with data on local trends of developing resistance to develop more comprehensive antibiograms. This is how we realized that 55% of infections in our area were resistant to trimethoprim-sulfamethoxazole. Having this system enabled us to educate HCPs that trimethoprim-sulfamethoxazole should not be the drug of choice for uUTI in our area and that it is much better to give nitrofurantoin or cephalexin because of local resistance patterns.

Altogether, increased collaboration and improved patient follow-up benefits everyone within a healthcare system, in ways that go beyond individual patient care.

Your Thoughts?
How do you collaborate with HCP colleagues in various settings to optimize the treatment of uncomplicated UTIs? Leave a comment below to join the discussion.