Inappropriate choices and durations of therapy for urinary tract infections (UTI) are a common and widespread problem. In this qualitative study, we sought to understand why primary care providers (PCPs) choose certain antibiotics or durations of treatment and the sources of information they rely upon to guide antibiotic-prescribing decisions. We conducted semi-structured interviews with 18 PCPs in two family medicine clinics focused on antibiotic-prescribing decisions for UTIs. Our interview guide focused on awareness and familiarity with guidelines (knowledge), acceptance and outcome expectancy (attitudes), and external barriers. We followed a six-phase approach to thematic analysis, finding that many PCPs believe that fluoroquinolones achieve more a rapid and effective control of UTI symptoms than trimethoprim-sulfamethoxazole or nitrofurantoin. Most providers were unfamiliar with fosfomycin as a possible first-line agent for the treatment of acute cystitis. PCPs may be misled by advanced patient age, diabetes, and recurrent UTIs to make inappropriate choices for the treatment of acute cystitis. For support in clinical decision making, few providers relied on guidelines, preferring instead to have decision support embedded in the electronic medical record. Knowing the PCPs’ knowledge gaps and preferred sources of information will guide the development of a primary care-specific antibiotic stewardship intervention for acute cystitis.

Background Use of antibiotics without a prescription is potentially unsafe and may increase the risk of antimicrobial resistance. We evaluated the effect of patient, health system, and clinical encounter factors on intention to use antibiotics without a prescription: (1) purchased in the United States (U.S.), (2) obtained from friends or relatives, (3) purchased abroad, or 4) from any of these sources. Methods Survey was performed January 2020 - June 2021 in six publicly-funded primary care clinics and two private emergency departments in Texas, U.S. Participants included adult patients visiting one of the clinical settings. Non-prescription use was defined as use of antibiotics without a prescription, and intended use was professed intention for future non-prescription antibiotic use. Results Of 564 survey respondents (33% Black and 47% Hispanic or Latino), 246 (43.6%) reported prior use of antibiotics without a prescription, and 177 (31.4%) reported intent to use antibiotics without a prescription. If feeling sick, respondents endorsed that they would take antibiotics: obtained from friends/relatives (22.3% of 564), purchased in the U.S. without a prescription (19.1%), or purchased abroad without a prescription (17.9%). Younger age, lack of health insurance and a perceived high cost of doctor visits were predictors of intended use of non-prescription antibiotics from any of the source. Other predictors of intended use were lack of transportation for medical appointments, language barrier to medical care, Hispanic or Latino ethnicity and being interviewed in Spanish. Conclusions Patients without health insurance who report a financial barrier to care are likely to pursue more dangerous non-prescription antimicrobials. This is a harm of the fragmented, expensive healthcare system that may drive increasing antimicrobial resistance and patient harm.

Objective: To validate the use of electronic algorithms based on International Classification of Diseases (ICD)-10 codes to identify outpatient visits for urinary tract infections (UTI), one of the most common reasons for antibiotic prescriptions. Methods: ICD-10 symptom codes (e.g., dysuria) alone or in addition to UTI diagnosis codes plus prescription of a UTI-relevant antibiotic were used to identify outpatient UTI visits. Chart review (gold standard) was performed by two reviewers to confirm diagnosis of UTI. The positive predictive value (PPV) that the visit was for UTI (based on chart review) was calculated for three different ICD-10 code algorithms using (1) symptoms only, (2) diagnosis only, or (3) both. Results: Of the 1087 visits analyzed, symptom codes only had the lowest PPV for UTI (PPV = 55.4%; 95%CI: 49.3–61.5%). Diagnosis codes alone resulted in a PPV of 85% (PPV = 84.9%; 95%CI: 81.1–88.2%). The highest PPV was obtained by using both symptom and diagnosis codes together to identify visits with UTI (PPV = 96.3%; 95%CI: 94.5–97.9%). Conclusions: ICD-10 diagnosis codes with or without symptom codes reliably identify UTI visits; symptom codes alone are not reliable. ICD-10 based algorithms are a valid method to study UTIs in primary care settings.

ObjectivesThe 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.DesignA preintervention and postintervention comparison with a contemporaneous control group was performed. During the first two study periods, we obtained baseline data and performed interviews exploring provider prescribing decisions for cystitis at both clinics. During the third period in the intervention clinic only, the intervention included a didactic lecture, a decision algorithm and audit and feedback. We used a difference-in-differences analysis to determine the effects of our intervention on the outcome and guideline adherence to antibiotic choice and duration.SettingTwo family medicine clinics (one intervention and one control) were included.ParticipantsAll female patients with uncomplicated cystitis attending the study clinics between 2016 and 2019.ResultsOur sample included 932 visits representing 812 unique patients with uncomplicated cystitis. The proportion of guideline-adherent antibiotic regimens increased during the intervention period (from 33.2% (95% CI 26.9 to 39.9) to 66.9% (95% CI 58.4 to 74.6) in the intervention site and from 5.3% (95% CI 2.3 to 10.1) to 17.0% (95% CI 9.9 to 26.6) in the control site). The increase in guideline adherence was greater in the intervention site compared with the control site with a difference-in-differences of 22 percentage points, p=0.001.ConclusionA multifaceted intervention increased guideline adherence for antibiotic choice and duration in greater magnitude than similar trends at the control site. Future research is needed to facilitate scale-up and sustainability of case-based audit and feedback interventions in primary care.

Background Use of antibiotics without a prescription (purchased in the United States (U.S.), purchased in other countries, or obtained from friends and relatives) is potentially unsafe and may increase the global risk of antimicrobial resistance. We evaluated the effect of patient, health system, and clinical encounter factors on intention to use antibiotics without a prescription. Methods Waiting room survey conducted from January 2020 and March 2021 in three continuity and three same-day public primary care clinics and two private emergency departments. Non-prescription use was defined as the consumption of antibiotics not prescribed for the individual’s current condition. Intended use was defined as professed intention to take antibiotics if feeling sick, without contacting a doctor, nurse, or clinic, in any of the following situations: 1) buying antibiotics without a prescription in the U.S., 2) buying antibiotics without a prescription in another country, and 3) getting antibiotics from friends or relatives. The effect of patient, health care system, and clinical encounter factors were studied using multivariate logistic regression. Results Of the 564 respondents, 247 (43.8%) reported prior use of non-prescription antibiotics; half of these instances involved penicillins (mostly amoxicillin). Overall, 177 (31.4%) of the respondents intended to use antibiotics without a prescription from one of the three sources (Figure 1). Younger age, lack of health insurance and high cost of doctor visits were predictors of intention to buy antibiotics without a prescription in the U.S. (Table 1). Predictors of intention to buy antibiotics without a prescription from other countries included younger age, being interviewed in Spanish, and reporting that a language barrier is a major problem for medical appointments. Lack of health insurance and high cost of physician visits were associated with the intention to use antibiotics obtained from relatives or friends. Conclusion Interventions aimed at reducing non-prescription antibiotic use should focus on addressing language barriers, ensuring health insurance coverage, and reducing financial barriers to primary care visits. Disclosures Larissa Grigoryan, MD, PhD, Rebiotix Inc: Grant/Research Support Michael K. Paasche-Orlow, MD, MPH, GlaxoSmithKline: Advisor/Consultant Barbara Trautner, MD, PhD, Genetech: Advisor/Consultant.