Improving the management of cystitis in healthy, non-pregnant women in the Netherlands: identification of patients that recover without antibiotics

Background & relevance

Suspecting a cystitis is the most common reason for women to contact their general practice. Often an antibiotic is prescribed. Antibiotic use has several negative consequences: antimicrobial resistance, adverse effects, medical costs, and ecological damage. Moreover, in half of healthy non-pregnant women, a cystitis can recover within a week without antibiotic use. This is safe: the risk of a pyelonephritis is very small. Antibiotic treatment is therefore not always necessary. In line with this, the cystitis guideline for Dutch general practitioners states that for healthy non-pregnant women a wait-and-see policy should be discussed with the patient. Previous research showed that both patients and health care providers seem to be open for a wait-and-see policy. However, it is yet unknown how often this takes place, what factors and considerations play a role in it and in whom the cystitis disappears.

Objectives & research questions

The aim of this study is to generate more knowledge about the course of untreated cystitis and patient characteristics associated with recovery, which can help the general practitioner (GP), the GP assistant and patient make a better decision about whether or not to use antibiotics. We will answer the following research questions:

1. How often are antibiotics not prescribed or delayed for cystitis in healthy, non-pregnant women and what are effects on symptoms, complications, and recurrences?
2. What patient characteristics are associated with use of a wait-and-see policy?
3. What patient characteristics are associated with spontaneous recovery?
4. What are considerations for, and experiences with a wait-and-see policy for prescribing antibiotics in this patient group?

Methods

We perform a mixed methods study to

1. quantify outcomes after application of a wait-and-see policy
2. to complement this with in-depth information on expectations and experiences of GPs, their assistants, and patients.

Quantitative part

We will use routine care data from Dutch general practices (covering about 8% of the total Dutch population) and primary care out-of-hours-services (that provide out-of-hours care for about 70% of the Dutch population) that participate in the Nivel Primary Care Database. This includes data on consultations, diagnoses, and prescribed medication. We include healthy, non-pregnant women with cystitis. We exclude children, males, pregnant women, women with comorbidities and women with prophylactic antibiotic use. We determine who did not receive an antibiotic prescription or delayed prescribing and how many women recovered, or had complications after 7, 30 and 60 days, or had a recurrence within the 10 months thereafter.

Qualitative part

We organize focus groups with 8-10 GPs and 8-10 GP assistants, and interviews with 12-15 patients. Topics to be discussed include expectations and experiences with the natural history of cystitis and factors associated with a wait-and -see policy. The multidisciplinary project team consists of a patient, GP assistant, GP researchers, and experts on cystitis, antibiotic prescribing, methodology and implementation of results.

Intended results & impact

The results of this study provide GPs, GP assistants and patients with the information that is needed to decide together on (not) using antibiotics for cystitis. Results can be used to update information for patients (via Thuisarts.nl) and for GPs (in guidelines). Results will be disseminated both to a national audience (infographic for patients, accredited webinars, conference and publication for GPs and GP assistants) and an international audience (peer reviewed international scientific journal and international conference). Data and meta data will be stored at a suited online platform such as DANS to ensure FAIR data sharing.