The management of urinary tract infections by community pharmacists: A state-wide trial : Urinary Tract Infection Pharmacy Pilot - Queensland (Service Evaluation Report - Approved April 2023)

Urinary tract infections (UTIs) have been listed as one of the top twenty reasons for visiting general practitioners (GP’s) in Australia [1]. Community pharmacies have been found to provide improved access to timely and effective treatment for a range of minor ailments, a term that has been adopted to describe minor illness or complaints, including uncomplicated UTIs, in Canada [2], the United Kingdom [3], Scotland [4] and New Zealand [5]. In Queensland, continuing general practice workforce shortages and maldistribution, exacerbated by the COVID-19 pandemic response, has resulted in increased waiting times and emergency department presentations [6]. Increasing the scope of practice for pharmacists to treat minor ailments, including issues such as reflux, minor burns and acute lower back pain, has been identified as one strategy for health departments to improve access to primary health care services [7]. However, concerns of increasing antibiotic resistance from community acquired infections [8] must be balanced against enabling pharmacists to prescribe antibiotics, which theoretically may increase the opportunity for increased antibiotic use and the potential for misdiagnosis in the primary care setting. A randomised controlled trial by Little and colleagues [9] comparing five different treatment approaches in the management of UTIs found there was no evidence that either using midstream urine analysis as an initial strategy to guide antibiotic prescribing or the use of midstream urine samples by medical officers as part of their overall clinical management, improved patient symptoms or outcomes, including symptom intensity and duration. The diagnosis of uncomplicated UTI is based primarily on history and symptoms of dysuria, urgency and frequency [10]. A meta-analysis by Bent and colleagues [11] found that women presenting to outpatient clinics with a least two symptoms of dysuria, urinary frequency or urinary urgency, and the absence of vaginal discharge, had an approximately 90% probability of having an acute urinary tract infection. In the Australian primary care setting, performing a mid-stream urinalysis before commencing antibiotic treatment is generally recommended [12]; however, treatment can be commenced empirically without urinalysis if clinically warranted [12]. The Australian Therapeutic Guidelines stated that ‘for nonpregnant women with a first episode of acute uncomplicated cystitis, urine culture and susceptibility testing may not be necessary; empirical therapy can be started based on symptoms alone’ [13]. Therefore, urine microscopy, culture and susceptibility testing are available to confirm infection and causative organism if required, but was not always recommended. Several international and national guidelines outline current best practice for the management of uncomplicated UTIs [10, 13-15]. Most recommend three days of trimethoprim as first or second-line treatment for non-pregnant women, if the risk of resistance to trimethoprim is low. This includes when trimethoprim has not been used in the past 3 months, previous urine culture indicated susceptibility (but trimethoprim was not used), and in younger people in areas where local epidemiology data suggest resistance is low [14]. Other treatment options include nitrofurantoin for 5 days, trimethoprim-sulfamethoxazole for 3 days, fosfomycin as a single dose, or pivmecillinam for 5 days [15]. In Australia, trimethoprim continues to be recommended as empirical therapy for acute cystitis because the risk of adverse outcomes from treatment failure is low [13], although nitrofurantoin for 5 days is also considered an alternative first-line treatment [13], with cefalexin for 5 days second line if trimethoprim or nitrofurantoin is not appropriate. Pivmecillinam is not available in Australia. The report prepared for Queensland Health by a Parliamentary Committee following an Inquiry into the establishment of a pharmacy council and transfer of pharmacy ownership had previously recommended developing and trialling options for an increased scope of practice for pharmacists [16]. In their response to the report, the Queensland Government committed to developing, implementing and evaluating a state-wide trial of provision of antibiotics for uncomplicate UTIs by pharmacists [17]. This prospective observational study evaluates the Urinary Tract Infection Pharmacy Pilot – Queensland (UTIPP-Q) initiative, which was the first initiative to be trailed following acceptance of the report recommendations. Legislative change allowing appropriately trained pharmacists to treat uncomplicated UTIs, including the provision of antibiotics, was facilitated by Queensland Health. Although, it was expected that results would be similar to previously conducted trials [2-5], the size and geographic diversity of Queensland (approximately 2.5 times the size of the state of Texas in the United States [18]) makes implementation of a state-wide service challenging. A mixed-methods evaluation was undertaken to assess the safety, effectiveness and acceptability to patients and the health workforce of providing a service to treat uncomplicated UTIs though community pharmacies. Of particular interest was: (i) pharmacist adherence to a structured prescribing protocol; (ii) safe and appropriate referral patterns; and (iii) effectiveness of first line treatments to achieve full symptom resolution. We focus on these outcomes in this report.

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