Clinical Audit: First-Line Treatment of Uncomplicated Urinary Tract Infection in Port Sudan Teaching Hospital, Sudan

Introduction

Up to Date. COM

Authers: Thomas M Hooton, MD; Kalpana Gupta, MD, MPH

Section editor: Stephan B Calder Wood, MD

Deputy Editor: Allysan Bloom, MD

Nitrofurantoin:

Monohydrate, macrocrystals (Macrobid) dosed at 100 mg orally twice daily for 5 days. Randomized trials suggest a 79–92% clinical cure rate with a five to seven day regimen, with minimal resistance promotion. Higher rates of failure occur with shorter courses. It has minimal propensity to select for resistant organisms.

NICE Guideline:

First choice: Nitrofurantoin, if estimated glomerular filtration rate (eGFR) >45 ml/minute.

Dose: 100 mg modified release twice daily (or, if unavailable, 50 mg four times daily) for 3 days.

Randomized trials suggest a 79–92% clinical cure rate with a five to seven day regimen.

Based on the available evidence, a 90% clinical cure rate is adopted as the audit standard when guidelines are followed.

Aim

To evaluate adherence to guideline-recommended use of Nitrofurantoin as first-line therapy for uncomplicated urinary tract infection and to identify barriers to its appropriate use.

Setting

The audit was conducted at a secondary care teaching hospital in Sudan, specifically Port Sudan Teaching Hospital, involving physicians working in Emergency Medicine and Internal Medicine.

Methods

This clinical audit was conducted in 2023 at Port Sudan Teaching Hospital, Sudan.

A total of 100 physicians were included. Participants were selected based on regular clinical presence in the emergency department.

Data were collected through structured focus group discussions.

Data analysis was performed using a Fishbone (Ishikawa) diagram.

Standards

- Nitrofurantoin should be first-line for uncomplicated UTI

- Correct dose and duration should be followed

- Target clinical cure rate: 90%

Results

Patient Factors:

- Incomplete adherence to antibiotics

Clinician Factors:

- Failure to use first-line therapy

- Concerns about side effects

- Reliance on colleagues rather than guidelines

System Factors:

- Limited drug availability

Treatment Factors:

- Short duration prescriptions (<3 days)

Discussion

There is a clear gap between guidelines and clinical practice. Barriers include clinician perception, system limitations, and prescribing habits.

Conclusion

Adherence is suboptimal. Improvement is required to achieve expected outcomes.

Recommendations

- Education and training

- Evidence-based prescribing

- Ensure drug availability

- Correct treatment duration

- Patient education

Re-Audit Plan

A re-audit should be conducted to assess:

- First-line prescribing improvement

- Compliance with duration

- Achievement of a 95% clinical cure rate benchmark