title: Urinary Tract Infections: Leading Initiatives in Selecting Empiric Outpatient Treatment (UTILISE).
abstract: BACKGROUND
  Overuse of fluoroquinolone antibiotics is associated with outbreaks of methicillin-resistant Staphylococcus aureus and of Clostridium difficile-associated diarrhea and increasing resistance in gram-negative organisms. Over the past decade, resistance of Escherichia coli to ciprofloxacin has increased in the Regina Qu'Appelle Health Region. In August 2011, an exploratory audit of the Regina General Hospital (RGH) emergency department showed that 20% of new antibiotic orders were for fluoroquinolones, and 60% of these new fluoroquinolone orders were for ciprofloxacin. It was postulated that ciprofloxacin was predominantly prescribed for outpatients with urinary tract infection.
  
  
  OBJECTIVE
  To develop, implement, and evaluate a best-practice algorithm for the empiric treatment of uncomplicated urinary tract infection in the RGH emergency department, as part of an educational initiative for emergency physicians.
  
  
  METHODS
  A literature review was conducted and local antibiogram data were analyzed to establish a best-practice algorithm for treatment of uncomplicated urinary tract infection in outpatients seen in the emergency department. A chart review was conducted from January to March 2011 to establish a baseline of empiric antibiotic use. An educational strategy targeting emergency physicians described changes in antibiotic resistance patterns in the health region, principles of antimicrobial stewardship, drivers of resistance, and the results of a literature review of best practice for urinary tract infection in outpatients. A post-intervention audit was conducted from January to March 2012 to determine changes in practice.
  
  
  RESULTS
  Comparison of results from the post-intervention audit with baseline data showed that adherence to best practice increased significantly, from 41% (39/96) before the intervention to 66% (50/76) after the intervention (odds ratio [OR] 2.81, 95% confidence interval [CI] 1.51-5.25; p < 0.001). There was also a significant change in overall antibiotic selection (OR 0.25, 95% CI 0.11-0.58; p < 0.001). Further analysis suggested that this significant change was driven by a decrease in use of ciprofloxacin, from 32% (31/96) to 11% (8/76).
  
  
  CONCLUSIONS
  Creation of a best-practice algorithm and education focused on emergency physicians significantly increased adherence to best practice and optimized antibiotic prescribing for outpatients with uncomplicated urinary tract infection by limiting overuse of fluoroquinolones, primarily ciprofloxacin.
authors.affiliation: , BSP, ACPR, was, at the time of this study, a pharmacy practice resident (2011/2012) with the Regina Qu'Appelle Health Region, Regina, Saskatchewan, and completed this project in partial fulfillment of the residency requirements. He is currently with the College of Pharmacy and Nutrition at the University of Saskatchewan, Saskatoon, Saskatchewan, as Coordinator of the Medication Assessment Centre.
authors.forename: Eric
authors.initials: E
authors.lastname: Landry
authors.affiliation: , BSP, PharmD, is with the Regina Qu'Appelle Health Region, Regina, Saskatchewan.
authors.forename: Linda
authors.initials: L
authors.lastname: Sulz
authors.affiliation: , MA, MSc, is with the Regina Qu'Appelle Health Region, Regina, Saskatchewan.
authors.forename: Ali
authors.initials: A
authors.lastname: Bell
authors.affiliation: , BSc, MD, CCFP(EM), is with the Regina Qu'Appelle Health Region, Regina, Saskatchewan.
authors.forename: Lane
authors.initials: L
authors.lastname: Rathgeber
authors.affiliation: , BSP, is with the Regina Qu'Appelle Health Region, Regina, Saskatchewan.
authors.forename: Heather
authors.initials: H
authors.lastname: Balogh
keywords: Escherichia coli resistance; emergency department; empiric treatment; fluoroquinolones; urinary tract infection