Do Urine Cultures for Urinary Tract Infections Decrease Follow-up Visits?

Jeremy Daniel Johnson, MD, MPH; Heather M. O'Mara, DO; Hyrum F. Durtschi, DO; Branko Kopjar, MD PhD, MS

Disclosures

J Am Board Fam Med. 2011;24(6):647-655. 

In This Article

Abstract and Introduction

Abstract

Background: No major clinical practice guideline recommends ordering a urine culture in the management of uncomplicated urinary tract infections (UTIs). In this era of increasing antibiotic resistance, our objective was to determine if ordering urine cultures for adult women with uncomplicated UTIs provides results that lead to a decrease in follow-up visits for continued UTI symptoms.
Methods: This was a retrospective cohort study from the outpatient family medicine clinic, Madigan Army Medical Center, Tacoma, WA. Seven hundred seventy-nine nondiabetic, nonpregnant, adult (aged 18–65 years) female patients (mean age ± SD, 32.9 ± 12.1 years) diagnosed with a UTI from November 2006 through March 2008. The main outcome measure was follow-up outpatient visits within 2 weeks for recurrent UTI symptoms.
Results: Of the 779 patients studied, 332 (43%) had no urine culture ordered as part of their management and 447 (57%) had a urine culture ordered. There was no significant difference in the rate of follow-up within 2 weeks for continued UTI symptoms between the cohort without urine culture (28 of 332; 8.4%) and the cohort with urine culture (39 of 447; 8.7%) (χ2 = 0.021; P = .89). In multivariate logistic regression, ordering a urine culture was not associated with a decreased rate of follow-up visits (adjusted odds ratio, 1.11; 95% CI, 0.65–1.90).
Conclusions: In adult women with uncomplicated UTI, ordering a urine culture was not found to be associated with a decrease in follow-up clinic visits. This finding is consistent with current guidelines that recommend against ordering a urine culture for uncomplicated UTIs.

Introduction

Uncomplicated urinary tract infections (UTIs), which include acute cystitis, are one of the most common presenting complaints in primary care. In 1997, UTIs accounted for seven million office visits and one million emergency department visits in the United States.[1] Numerous worldwide publications and practice guidelines have recommended against the use of routine urine cultures in uncomplicated UTIs for cost-effectiveness reasons.[2] [12] Despite these recommendations, one study found that primary care physicians (family medicine, general internal medicine, obstetrics/gynecology, and emergency medicine) ordered urine cultures 30% of the time in the management of uncomplicated UTIs, and another study found that they ordered urine cultures 32% to 57% of the time depending on location and patient's insurance type.[13,14]

In 1984 Dr. Henry Schultz and his colleagues[15] published a prospective study of UTIs in a primary care acute illness service. They argued that, for conventionally managed UTIs, because medications accounted for only 10% to 15% of the cost and physician fees only 22%, any cost savings would have to come from a reduction in the number of laboratory tests. Although this conclusion may have been valid at the time of the study, its validity today may be mitigated by rising antibiotic resistance, changing prescribing patterns, cost of antibiotics, and other factors. Schultz et al[15] found that clinical symptoms of frequency, urgency, and dysuria seemed to be better guides to management than urine cultures, and urine culture susceptibility testing did not contribute to the management of UTIs. Significant limitations to the study were that all patients received a urine culture and no urine cultures revealed bacteria resistant to the antibiotic used for treatment, which is far from the current situation of drug-resistant bacteria. Since the 1984 Schultz et al[15] study, no major clinical practice guideline, cost-effectiveness analysis, or medical society has recommended a urine culture as part of the management of an uncomplicated UTI.[5,16] [21] No study in the published literature has yet looked at whether ordering a urine culture at the time of diagnosis and treatment of UTI decreases follow-up visits.

Our study evaluated the current practice at three family medicine clinics at Madigan Army Medical Center in Tacoma, Washington, through empiric study of 779 patients with presumed uncomplicated UTIs. This retrospective cohort study looked at the percentage of instances in which providers ordered urine cultures for patients with uncomplicated UTIs, and it evaluated the patients' management to see if obtaining a urine culture decreased follow-up visits for continued UTI symptoms. Secondary outcomes were based on the questions, (1) Does ordering a urine culture increase the percent of patients who have a second antibiotic prescribed within 2 weeks? and (2) Does ordering a urine culture decrease the percent of patients who call their provider with a complaint of continued UTI symptoms?

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