Follow-up of patients with urinary tract infections discharged from the emergency department: a mixed methods study

Abstract

Objectives: To evaluate the quality of culture follow-up after emergency department (ED) discharge in patients with urinary tract infections (UTIs).

Methods: This convergent mixed methods study included an observational cohort study and a qualitative interview study in UTI patients discharged from the ED of a Dutch university hospital. The primary outcomes of the observational study were the proportion of patients requiring adjustment of antibiotic therapy after culture review, and the proportion of patients in whom these adjustments were made. Logistic regression identified factors associated with these outcomes. Interviews assessed patient experiences and transcripts were analysed using inductive thematic content analysis. Integration of the results informed recommendations for high-quality follow-up.

Results: Out of 455 patients, 285 (63%) required culture-based treatment adjustments. In most patients, no adjustments were made (239/285, 84%). De-escalation was most frequently omitted (98%), followed by discontinuation of antibiotics (92%). A mean of 7.1 (SD 3.8) antibiotic days per patient could have been avoided in 103 patients. Patients with diabetes were less likely to require adjustments (aOR 0.50, 95%-CI 0.29-0.85). Patients with moderate or severe renal impairment (aOR 4.1, 95%-CI 1.45-11.33; aOR 4.2, 95%-CI 1.50-11.94) or recurrent UTIs (aOR 5.0, 95%-CI 2.27-11.18) were more likely to have received necessary adjustments. Twelve interviews also revealed varying degrees of follow-up. Three themes were identified: 'information and communication', 'coordination and accessibility of care' and 'individual needs and preferences'. Recommendations for high-quality follow-up advocate a person centred approach.

Conclusions: This study highlights the importance of urine culture follow-up after ED discharge, mainly to reduce unnecessary antibiotic treatment, promote de-escalation and improve patient experience.

Figure 1.

Flowchart of patient inclusion observational study. Patients were initially identified based on a urine culture being performed and being discharged from the ED. Patients were then excluded if they did not have a urinalysis or if they had an opt out status (i.e. they did not agree to their data being reused). Patients with a negative urinalysis were then excluded. Finally, patients without a clinically suspected UTI or who had attended the ED more than once in the previous 3 months were excluded.