Urinary tract infections (UTIs) in women are one of the most common reasons for consultations in primary care settings. These infections, while often uncomplicated, significantly impact the quality of life for affected individuals. Current clinical guidelines recommend symptomatic treatment and delayed antibiotic prescriptions for women with mild to moderate UTI symptoms who prefer to avoid immediate antibiotic therapy. Despite these recommendations, antibiotics remain the first-line treatment in most primary care consultations due to their ability to reduce the duration of symptoms and slightly decrease the risk of complications such as pyelonephritis.

The widespread reliance on antibiotics has raised concerns about antimicrobial resistance, a growing public health threat. Resistance complicates treatment options, especially when second-line antibiotics like fluoroquinolones are overprescribed. Addressing these challenges requires systematic efforts to promote antibiotic supervision, ensuring that antibiotics are used judiciously and in line with clinical guidelines.

The Overuse of Antibiotics in UTI Treatment

Although first-line antibiotics are recommended for treating uncomplicated UTIs, second-line antibiotics such as fluoroquinolones are still frequently prescribed inappropriately. In Germany, for example, regional prescription rates for fluoroquinolones range from 38% to 54%. This overuse persists despite guidance advocating their limited use to prevent resistance. Furthermore, non-antibiotic treatments, such as symptomatic management with over-the-counter medications, are rarely discussed or offered to patients during consultations.

The overprescription of antibiotics reflects a disconnect between clinical guidelines and real-world practice. Many general practitioners (GPs) prioritise antibiotics due to the perceived urgency of patient symptoms and the assumption that patients expect immediate relief. However, this approach risks contributing to antibiotic resistance and limits the adoption of alternative treatment strategies. Addressing this issue requires targeted interventions to realign prescribing habits with evidence-based recommendations.

Multimodal Interventions

Recent studies have explored strategies to reduce inappropriate antibiotic use for UTIs, with multimodal interventions emerging as a promising solution. One such intervention sought to reduce the prescription of second-line antibiotics by combining multiple components, including guideline recommendations, regional resistance data, and feedback on prescribing behaviours. This intervention included quarterly feedback on individual prescribing rates, benchmarking against peers, and telephone counselling to support clinical decision-making.

Practices implementing the intervention achieved a significant reduction in the use of second-line antibiotics, as well as an increase in UTI cases treated without antibiotics. Importantly, these improvements did not lead to higher rates of complications such as pyelonephritis. The intervention group reduced quinolone prescriptions to 6%, nearly meeting the European quality indicator of less than 5% for cystitis. This demonstrated that a structured, evidence-based approach could successfully shift prescribing behaviours while maintaining patient safety.

Regional Resistance Data

One of the key innovations in the intervention was the inclusion of regional resistance data. Resistance rates vary by region, and localised data can provide valuable insights for adapting antibiotic prescribing. Despite being recommended in national and international guidelines, regional resistance data are rarely utilised in routine clinical practice. This study highlighted the potential of resistance data to inform treatment decisions, enabling GPs to select antibiotics with lower resistance rates and better align with guideline recommendations.

In recent years, Germany has seen a decline in fluoroquinolone prescriptions, from 29.4% in 2015 to 8.7% in 2019, due in part to increased awareness of resistance risks. The intervention capitalised on this trend by providing GPs with actionable data to further reduce second-line antibiotic use. As resistance rates to fluoroquinolones decreased, the study observed lower recurrence rates for UTIs, highlighting the importance of using first-line antibiotics whenever possible. Incorporating regional resistance data into clinical workflows is a practical and effective step toward improving antibiotic supervision.

Sustained Results and Comparisons with Other Interventions

The study’s results were sustained over a one-year period, with the greatest improvements observed in practices that initially had high rates of second-line antibiotic prescriptions. This suggests that targeting high prescribers could yield the most significant benefits. Peer discussions and educational measures, similar to those implemented in Sweden’s STRAMA program, further supported the effectiveness of the intervention. These measures emphasise the to foster collaboration and knowledge-sharing among healthcare providers to improve prescribing practices.

Comparing this intervention with other studies demonstrated similar successes and challenges. For example, some interventions aimed at respiratory tract infections achieved reductions in antibiotic use by employing audit-and-feedback mechanisms, peer benchmarking, and educational materials. However, the results were often mixed, with unintended consequences such as increased overall antibiotic use in some cases. This highlights the need for carefully designed interventions that address specific clinical contexts without inadvertently encouraging overprescription.

Addressing Limitations and Barriers to Implementation

While the study demonstrated clear benefits, it also faced several limitations. Data extraction was a significant challenge, with some practices excluded due to insufficient or missing data during the Covid-19 pandemic. The lack of blinding among practice teams may have introduced biases, though the use of objective endpoints and data validation measures helped mitigate this risk. Additionally, delayed prescriptions, an accepted approach for managing uncomplicated UTIs, were not consistently documented in electronic medical records, making it difficult to assess their true impact.

Resource-intensive components, such as collecting resistance data and providing feedback, present additional barriers to scaling the intervention. However, advancements in digital health infrastructure could address these challenges. Automated data extraction tools and integrated electronic health records can streamline the process, ensuring that clinicians have access to real-time information on resistance rates and prescribing benchmarks.

Importance of Non-Antibiotic Treatments

Another critical aspect of antibiotic supervision in UTIs is the promotion of non-antibiotic treatment options. Many women with mild to moderate UTI symptoms are open to trying non-antibiotic therapies as a first-line treatment. Despite this, non-antibiotic treatments are rarely discussed during primary care consultations. Increasing awareness and education about these alternatives could reduce unnecessary antibiotic use and provide patients with effective symptom management options.

Qualitative data suggest that patients value clear communication and shared decision-making when discussing treatment options. By engaging patients in conversations about their preferences and providing evidence-based information on non-antibiotic therapies, clinicians can foster trust and support better outcomes. Integrating these discussions into routine practice will require a cultural shift toward prioritising patient-centred care and emphasising the importance of supervision.

Implications for Clinical Practice

The findings of the study have significant implications for clinical practice. By combining guideline recommendations, resistance data, and structured feedback, the intervention demonstrated that it is possible to improve antibiotic prescribing behaviours in primary care. Practices with high rates of second-line antibiotic use saw the most substantial improvements, indicating that future interventions should focus on supporting these high prescribers.

The inclusion of regional resistance data was particularly impactful, highlighting the need for localised approaches to supervision. Resistance data not only inform treatment decisions but also provide valuable insights for updating guidelines and policies. Warranting that this information is readily available and easily accessible to clinicians will be crucial for sustaining progress in antibiotic supervision.

Research and Innovation

While the study provides a strong foundation for improving UTI treatment, additional research is needed to refine and expand these strategies. Future studies should investigate the most effective components of multimodal interventions, such as the relative impact of education, feedback, and resistance data. Understanding these dynamics will help optimise interventions and maximise their effectiveness in different clinical settings.

Further research into non-antibiotic treatments is also essential. As new evidence emerges, guidelines must be updated to reflect the latest insights and provide clinicians with clear recommendations. This includes establishing updated quality indicators for antibiotic prescribing, which take into account the growing emphasis on non-antibiotic options.

Technological innovation will play a key role in supporting these efforts. Automated systems for data collection, analysis, and feedback can reduce the administrative burden on clinicians and enable more efficient implementation of supervision programs. By leveraging digital tools and fostering collaboration among stakeholders, healthcare systems can build on the successes of this study to create more sustainable and effective solutions.

Conclusion

Antibiotic supervision is a critical priority in managing UTIs, as resistance rates continue to pose challenges to effective treatment. This study demonstrates that a multimodal intervention, combining guideline adherence, resistance data, and targeted feedback, can significantly improve prescribing practices while maintaining patient safety. By enabling more informed and evidence-based decisions, these interventions offer a practical path forward for addressing the overuse of antibiotics in primary care.

As the healthcare community works to balance patient needs with the principles of supervision, it is essential to prioritise education, innovation, and collaboration. Through continued research and the adoption of best practices, clinicians can ensure that UTIs are managed safely and effectively, reducing the burden of resistance and improving outcomes for patients. This comprehensive approach lays the foundation for a more sustainable and patient-centred future in UTI care.

Reference

Schmiemann, G., Greser, A., Maun, A., Bleidorn, J., Schuster, A., Miljukov, O., Rücker, V., Klingeberg, A., Mentzel, A., Minin, V., Eckmanns, T., Heintze, C., Heuschmann, P., & Gágyor, I. (2023). Effects of a multimodal intervention in primary care to reduce second line antibiotic prescriptions for urinary tract infections in women: parallel, cluster randomised, controlled trial. BMJ (Clinical Research Ed.), 383, e076305. https://doi.org/10.1136/bmj-2023-076305