The Five Ds of Outpatient Antibiotic Stewardship for Urinary Tract Infections

Abstract

Urinary tract infections (UTI) are one of the most common indications for antibiotic prescriptions in the outpatient setting. Given rising rates of antibiotic resistance among uropathogens, antibiotic stewardship is critically needed to improve outpatient antibiotic use, including in outpatient clinics (primary care and specialty clinics) and emergency departments. Outpatient clinics are in general a neglected practice area in antibiotic stewardship programs, yet most antibiotic use in the United States is in the outpatient setting. This article provides a comprehensive review of antibiotic stewardship strategies for outpatient UTI in the adult population, with a focus on the "five Ds" of stewardship for UTI, including right diagnosis, right drug, right dose, right duration, and de-escalation. Stewardship interventions that have shown success for improving prescribing for outpatient UTI are discussed, including diagnostic stewardship strategies, such as reflex urine cultures, computerized decision support systems, and modified reporting of urine culture results. Among the many challenges to achieving stewardship for UTI in the outpatient setting, some of the most important are diagnostic uncertainty, increasing antibiotic resistance, limitations of guidelines, and time constraints of stewardship personnel and front-line providers. This article presents a stewardship framework, built on current evidence and expert opinion, that clinicians can use to guide their own outpatient management of UTI.

Keywords: antibiotic stewardship; emergency department; outpatient; primary care; urinary tract infections.

FIG 1

Timeline of antibiotic development, antimicrobial resistance, and the advent of antibiotic stewardship.

FIG 2

The 5 Ds of antibiotic stewardship for UTI.

FIG 3

Diagnostic stewardship strategies for outpatient UTI. Preanalytical, analytical, and postanalytical stewardship strategies function as road signs (stop signs, caution signs, and forks in the road) that give instruction and guidance to health care providers, increasing the likelihood that providers reach the correct destination (right diagnosis). A stewardship stop sign causes clinicians to pause to rethink a diagnosis of UTI, a stewardship fork in the road helps providers to interpret clinical information and reach the right diagnosis, and a stewardship caution sign improves the collection and interpretation of urine tests.