Of 8,942 physicians, 2,172 (24.3%) responded. Of these, 32 responses were excluded because of missing data. Respondents did not differ from nonrespondents in gender (82% male), year of medical school graduation (median, 1979), and practice type (86% community based). The response rate was slightly higher among board-certified physicians (82% vs 78%), as we have found in other surveys of practicing physicians.10
Respondents saw a median of 5 patients per week with a primary complaint of dysuria (average, 7). They reported a median of 50 hours per week in patient care, 35% practiced with 5 or fewer physicians, and more than half had less than 1% of their patient care paid for on a capitation basis.
With regard to tests ordered for patients with dysuria, most respondents (79%) said they “usually or always” order a microscopic urinalysis, but only 30% usually order urine culture ()The two leading reasons given for not ordering culture were that it is too costly for the patient (76%) and that it rarely affects the treatment (74%). When compared with other specialties, obstetricians were more likely to order culture and sensitivity analysis (44%), but less likely to order microscopic urinalysis and leukocyte esterase (41%). Emergency medicine physicians were more likely to obtain leukocyte esterase (71%). When asked what tests they did in the office, most said they do dipstick urinalysis (93%) and microscopic urinalysis (80%), but only 29% said they obtained a urine culture. These questions regarding tests done in the office were probably not meaningful for emergency medicine physicians.
Diagnosis and Management Choices in Patients Suspected of Having Uncomplicated Urinary Tract Infection, Analyzed by Specialty*
We asked what threshold number of colony-forming units (CFU) per milliliter would be diagnostic of acute infection if a urine culture is obtained. The majority (55%) chose 105
CFU or greater, and few (6%) chose the 102
CFU recommended by Stamm and colleagues.4
The number of CFU respondents required for starting antibiotic treatment was lower, although the majority (63%) chose 104
CFU or greater. These estimates did not vary by specialty.
Regarding duration of antibiotic therapy, most chose either 2 to 5 days or 6 to 10 days (). Those in internal medicine and emergency medicine favored the shorter course (2 to 5 days), and those in obstetrics favored the longer course (6 to 10 days). Other differences are shown in . Although most respondents said they prescribe trimethoprim-sulfamethoxazole as drug of first choice in treating uncomplicated UTI, 13% chose nitrofurantoin. These were mostly obstetricians, 46% of whom selected nitrofurantoin as their first choice ().
Antibiotic of First Choice in Treating a 30-Year-Old Woman with Cystitis*
We asked physicians what they do when the urine culture result comes back negative after they have previously prescribed antibiotics. Only 23% said they would contact the patient and stop the antibiotics; most would either continue the antibiotics unchanged (47%) or shorten the course (22%). Eight percent chose “other.” In the case of a woman with dysuria whose urine culture is positive for WBC and bacteria, 63% would start antibiotics without further testing. Fewer than 1% would wait for culture results, and 34% would order culture and start antibiotics without waiting for the culture results. Where the results of microscopic urinalysis are “equivocal (5–10 leukocytes, few bacteria),” 39% would start antibiotics and do no further testing, 16% would wait for the culture result, and 39% would start antibiotics and order culture. When asked to estimate what percentage of patients seen for dysuria actually have a UTI, the greatest number of respondents (54%) chose 50% to 75%. Most (81%) thought that more than 75% of UTIs are cured by their treatment.