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Warren J. McIsaac, MD, MSc; Donald E. Low, MD; Anne Biringer, MD; Nicholas Pimlott, MD, PhD; Michael Evans, MD; Richard Glazier, MD, MPH

Arch Intern Med. 2002;162:600-605.

Background  Guidelines for the management of acute cystitis support empirical antibiotic treatment; however, up to half of symptomatic women have negative urine cultures.

Objective  To determine whether empirical treatment leads to unnecessary antibiotic prescriptions in women with symptoms of acute cystitis.

Methods  A cohort of 231 women (defined as females aged 16 years and older) presenting to family physicians' offices with symptoms of cystitis underwent a standardized clinical assessment, urine dip testing, and culture. Recommendations for urine testing and antibiotic treatment under 3 empirical strategies were compared with observed physician management and a logistic regression model for the outcomes of antibiotic prescriptions, urine culture testing, and unnecessary antibiotics, defined as a prescription where the subsequent urine culture was negative.

Results  There were 123 positive urine cultures (53.3%). Physicians prescribed antibiotics to 186 women (80.9%), of whom 74 (39.8%) were culture negative. Unnecessary antibiotic use was similar for 2 guidelines recommending empirical antibiotic treatment without testing for pyuria (41.4% and 40.6%). Treating women with classic cystitis symptoms and pyuria would have decreased unnecessary antibiotic use (26.2%; P = .02) but resulted in fewer women with confirmed urinary tract infection receiving immediate antibiotics (66.4% vs 91.8% usual care; P<.001). A derived prediction model incorporating testing for pyuria and nitrites would also have reduced unnecessary antibiotic use (27.5%; P = .03), but more women with confirmed urinary tract infection would have received immediate antibiotics (81.3%; P = .01).

Conclusions  Empirical antibiotic treatment of acute cystitis in women without testing for pyuria promotes unnecessary antibiotic use. A simple decision rule provides for prompt treatment of infected women while reducing antibiotic overuse and unnecessary urine testing.

From the Mt Sinai Family Medicine Centre (Drs McIsaac and Biringer) and Department of Microbiology (Dr Low), Mt Sinai Hospital, Family Healthcare Research Unit, Department of Family and Community Medicine (Drs McIsaac, Pimlott, Evans, and Glazier) and Department of Laboratory Medicine and Pathobiology (Dr Low), University of Toronto, Department of Microbiology, The Toronto Hospital (Dr Low), Family Medicine Unit, Women's College Hospital (Dr Pimlott), Family Medicine Unit, University Health Network–Toronto Western Division, Toronto (Dr Evans), and Department of Family and Community Medicine and Inner City Health Research Unit, St Michael's Hospital (Dr Glazier), Toronto, Ontario.

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