More than half of UTIs treated inappropriately in primary care in SG

New research from Singapore has shown that most patients with uncomplicated urinary tract infections (UTIs) being treated in primary care receive inappropriate antibiotics.

According to data on 369 patients (median age 58 years, 73.4 percent Chinese) collected from seven local primary care clinics between January and June 2023, 197 (53.4 percent) had inappropriate antibiotic prescriptions. This figure is similar to that reported in Australia (45.6 percent) and the US (52.9 percent) but sits between the lower rate in South Korea (26.9 percent) and the higher rate in Switzerland (84.7 percent). [Sci Rep 2025;15:15055; Infect Dis Health 2019;24:75-81; PLoS One 2022;17:e0277713; Infect Dis Clin Pract 2024;32:e1385; BMC Fam Pract 2020:21:125]

Of the inappropriate antibiotic prescriptions, 35 (17.8 percent) resulted from an inaccurate uncomplicated UTI diagnosis, 136 (69.0 percent) deviated from the 2023 Ministry of Health Singapore Clinical Guideline, and 26 (13.2 percent) were due to both an inaccurate diagnosis and guideline deviation. Amoxicillin/clavulanate (47.2 percent) was the most frequently prescribed antibiotic, followed by nitrofurantoin (32.8 percent).

A sensitivity analysis including foul-smelling urine as a symptom in consideration of uncomplicated UTI diagnosis yielded consistent findings.

“[The high number of inappropriate antibiotic prescriptions] may be attributed to outdated antibiotic guidelines as updated guidelines reflecting local antibiograms were only released in November 2023. Therefore, our study is timely to inform the implementation of the newly updated guidelines, which can potentially improve the judicious use of antibiotics for uncomplicated UTI treatment in Singapore,” the investigators said.

Key predictors

The odds of receiving inappropriate antibiotics were greater among patients with an antibiotic drug allergy (odds ratio [OR], 2.49, 95 percent confidence interval [CI], 1.29–4.81; p=0.006) and among those with multiple complaints and diagnoses within the same consultation (OR, 1.32, 95 percent CI, 1.09–1.61; p=0.005). The clinic visited also factored in the appropriateness of antibiotic prescriptions, with the odds of prescribing inappropriately being more than twofold greater in clinics E (OR, 2.84, 95 percent CI, 1.28–6.30) and G (OR, 2.84, 95 percent CI, 1.14–7.09) than in clinic D (p=0.004).

In separate analyses of diagnostic accuracy of uncomplicated UTIs and alignment of prescription with guideline, physicians had increased odds of making an inaccurate diagnosis of uncomplicated UTI with an increasing number of visit diagnoses (OR, 1.67, 95 percent CI, 1.31–2.12; p<0.001).

Meanwhile, physicians were more likely to give a prescription that was not in line with guideline when faced with patients with an antibiotic drug allergy (OR, 2.52, 95 percent CI, 1.33–4.76; p=0.005). Physicians at clinics A, E, and G also had greater odds of giving prescriptions not in line with guideline compared with those at clinic D (A: OR, 2.20, 95 percent CI, 1.06–4.58; E: OR, 3.40, 95 percent CI, 1.55–7.47; G: OR, 3.85, 95 percent CI, 1.54–9.65).

Considering the said factors that influenced appropriate antibiotic prescription in primary care, the investigators recommended the implementation of clinical decision support tools, the adoption of shared decision-making practices, and the provision of continuing medical education.

Having a shared discussion with patients who present with multiple complaints and focusing the consultation on their most pressing acute complaint may reduce cognitive load among physicians, allowing greater capacity to gather a detailed history, physical examination, and investigations to formulate an accurate diagnosis, the investigators explained.

“Although this might generate greater demand for future appointments and inconvenience patients who must make multiple visits, it is an acceptable trade-off for optimal antimicrobial treatment, which brings about good clinical outcomes and treatment success for the individual and reduces risk of antimicrobial resistance for the society,” they said.

Meanwhile, continuing medical education helps keep physicians informed of the latest clinical guidelines and align empirical antibiotic prescriptions, the investigators continued. Technology can also be harnessed with the use of clinical decision support tools to assist in accurate antibiotic choices. “[These strategies] can improve antimicrobial stewardship practices and form an effective and sustainable strategy moving forward.

“As it remains to be seen if the current updated local antibiotic guidelines and other future interventions will positively influence antibiotic prescribing and antimicrobial stewardship in primary care, future studies using our study’s PPS methodology can be done to assess the impact of such interventions,” they added.