Antimicrobial stewardship and economic evaluation of urinary tract infection management in primary health care in Tunisia

Background
Inappropriate antibiotic prescriptions significantly contribute to antimicrobial resistance and are common in urinary tract infections (UTI) in primary health care. Tunisian guidelines were developed to improve UTI management for General Practitioners (GPs).

Objectives
This study aimed to evaluate GP adherence to Tunisian guidelines when prescribing antibiotics and the use of diagnostic tools for UTIs, as well as to compare current costs to those expected from guideline adherence.

Material and methods
This descriptive, cross-sectional study enrolled GPs managing patients with UTI in Sousse, Tunisia. Appropriate use of diagnostic tools and antibiotic prescriptions was evaluated. A costing model was built to compare costs between current practice and guideline adherence from a patient and country perspective for cystitis.

Results
330 prescriptions were collected from 76 GPs. Simple cystitis was most commonly diagnosed (69.4%). Urine dipsticks were appropriately used to diagnose 20% of cystitis cases. Urine cultures were used despite not being recommended in 45% of cystitis cases. The antibiotic prescription rate for UTI was high (92%). Overall, 20.7% of cases adhered to the guidelines. Adherence was correlated to work in the public sector and reading the guidelines. The costing model predicted that the full adherence of antibiotic prescriptions and diagnostic tool use to cystitis guidelines could save EUR 1,698,403 annually.

Conclusions
In Tunisia, GP adherence to UTI treatment guidelines is low. Our costing model indicates guideline adherence could result in substantial savings.