Case Study Week 5 : Managing Chronic Urinary Tract Infections in Primary Care
Before reading the Case Study, learn more about the 5 D's of an Antibiotic Stewardship here
Patient Background:
Name: Mary Thompson
Age: 68
Gender: Female
Medical History: Type 2 diabetes, hypertension, recurrent urinary tract infections (UTIs) (6 episodes in the past year)
Medications: Metformin, Lisinopril, Aspirin 81 mg, Nitrofurantoin (prophylactic)
Presentation:
Mary Jones, a 68-year-old Caucasian female, presents to the clinic with complaints of urinary urgency, burning sensation, and lower abdominal discomfort for the past three days. She reports a history of recurrent UTIs despite multiple courses of antibiotics. She follows proper hygiene, stays hydrated, and has tried cranberry supplements but continues to experience frequent infections.
Clinical Findings:
Vital Signs: BP 138/82 mmHg, HR 78 bpm, Temp 99.2°F, RR 16, SpO2 98% on room air
Physical Exam: Mild suprapubic tenderness, no CVA.
Urinalysis: Positive for leukocyte esterase, nitrites, WBCs >100/HPF
Urine Culture: Pending
Setting:
Primary Care Clinic in a urban upstate NY area.
Challenge: Antibiotic Resistance due to Frequent UTI Treatment
Solution: Develop and Utilize a Antibiotic Stewardship and Alternative Prevention Strategies for Urinary Tract Infections.
How can AI heal healthcare ? 👍
Interdisciplinary Team:
Family Nurse Practitioner
Conducts patient assessment and order diagnostic tests
initiates empirical antibiotic therapy while awaiting culture results
Refers the patient to specialists for further evaluation
Provide patient education on UTI prevention and self care strategies.
Physician
Collaborates with the FNP to manage complex cases
Review lab results and recommends further diagnostic imaging if needed
Assists in escalating care if the patient's conditions worsens (ER, Urgent Care)
Medical Assistants
Collaborates with the FNP to manage complex cases
Review lab results and recommends further diagnostic imaging if needed
Assists in escalating care if the patient's conditions worsens (ER, Urgent Care)
Provide patient handouts on hygiene and preventive care
Nurses
Administer medications if prescribed ( IV antibiotics in severe cases)
Provide education on prescribed medication and why it was prescribed for the patient
Educate the patient on proper medication use and hydration
Ensure follow-up appointments are scheduled with specialists
Infectious Disease Specialist
Reviews urine culture results to ensure appropriate antibiotic selection
Assesses the possibility of antibiotic resistance due to frequent infections
Recommends antibiotic stewardship strategies to reduce unnecessary antibiotic use
Urologists
Evaluates for underlying structural abnormalities or bladder dysfunction that may contribute to recurrent infections
Orders necessary imaging (Ultrasound or cystoscopy) if needed.
Discusses alternative treatment options such as low-dose prophylactic antibiotics or vaginal estrogen therapy
Pharmacist
Reviews current medications to assess potential problems or interactions
Educates patient on proper antibiotic use and adherence
Provides recommendations for non-antibiotic preventive strategies
Nutritionist
Advises on dietary changes that may support Urinary Tract health
Discuss the use of probiotics in maintaining a healthy urinary microbiome
Care Coordinator/ Case Management
Provide community resources
coordinate ongoing educational and support
Manages medications and patient adherence
Coordinates follow up appointments with specialists
CDS System Design and Implementation:
Needs Assessment: Identify gaps in current process of chronic UTI's in patients in the primary care setting. Evaluate: Inconsistent ABX stewardship, lack of standardized Prevention and Delayed Identification of Chronic UTI's and no streamline process for patient to be referred to a specialists.
Data Elements: EHR to trigger alerts and provide decision support for providers. For example: Patient demographics, medical history, medication history and lab data.
Algorithm Development: Rule bases algorithm to provide clinical decision making for chronic UTI management.
CDS Algorithm Workflow:
1. Patient Identification:
A UTI risk score is generated based on recurrence history (>3 UTIs in 12 months) and risk factors.
An alert is triggered in the EHR if a patient meets criteria for chronic UTI.
2. Diagnostic Guidance:
The system recommends urinalysis and urine culture before antibiotic prescription.
It flags possible antibiotic resistance based on past culture results.
3. Treatment Recommendations:
The CDS suggests first-line antibiotics based on local resistance data.
If recurrence is high, it recommends infectious disease consultation.
Non-antibiotic options (e.g., vaginal estrogen for postmenopausal women, probiotics) appear as decision prompts.
4. Referral & Follow-Up:
If high-risk factors are detected, an automatic referral suggestion to a urologist or infectious disease specialist appears.
The system sends follow-up reminders to patients via the patient portal
5. EHR Integration: Must support different level of providers workflow
Automated alerts: flag patients with recurrent UTI's and antibiotic resistance directly in the patient chart
Pre-populated order sets with UA's, Urine Cultures and recommended antibiotics
Provider support popups- Non intrusive alerts providing real time recommendations for UTI prevention and antibiotic choice.
Referral link built in within the EHR system to continue patient care beyond the primary care office
Utilization of patient engagement tools such as patient portals and application for prevention strategies.
6. Training and Education to Implement CDS
FNP
Focus on cup to date clinical guidelines for chronic UTI management, CDS navigation.
Hands on EHR demos, case based training
Physicians
Review of antibiotic stewardship strategies, CDS alert interpretation training.
CME session and grand rounds weekly.
Pharmacists
Antibiotic Stewardship training, synthesize culture dats and counsel patients on prevention at medication dispensing
Team workshops
IT Specialists
Troubleshoot system
ensure EHR go live date run smooth
Point of contact for technical training sessions and information
Evaluation:
After implementation of this CDS system, there was a 30 % decrease in UTI related visits to the primary care clinic over 6 months.
There was a 45% increase in non - antibiotic use interventions (probiotics, vaginal estrogen's and nutritional counseling).
There was a 25% decrease in unnecessary antibiotic prescriptions through the utilization of the antibiotic stewardship
Faster referral process with use of the CDS system through the EHR and cut down wait time by 15% overall.
Results:
Cut down on waiting time to be seen in office
Less patients returning or being admitted to hospital for complication reoccurring UTI's
There are now monthly provider feedback sessions
Patient satisfaction scores are up after implementation of CDS system
IT Specialists are leading staff feedback session monthly
What other studies say about the implementation of CDS systems for UTI prediction:
" The system provides the clinician with this prediction at an earlier stage in the diagnostic process. This enables the clinician to withhold the administration antibiotics, to look for other causes of infection or to recognize asymptomatic bacteriuria in case no UTI is predicted. In an exploratory analysis, we combine the predictive performance of the CDSS as a whole with an analysis of antibiotic prescriptions surrounding urine cultures to provide an estimate of the potential impact the system might have on prevention of inappropriate prescription of antibiotics. We calculated that the use of the system could result in a reduction of antibiotic prescriptions of up to 15.2% for the target population in our setting, although this number is expected be lower in clinical practice." ( De Vries et al., 2022, p. 13).
Conclusion:
This CDS System improves treatment, patient safety and enhances teamwork within the interdisciplinary network identified. Through utilization of an antibiotic stewardship, algorithms, support data pop-ups in the EHR and use of patient friendly applications, this ensures patients are being treated appropriately based on real time data. This system would allow for better patients outcomes while reducing the UTI recurrence and antibiotic resistance. "Available evidence suggests overuse of antibiotics contributes significantly to development and spread of resistance, and approximately 50% of outpatient antibiotic prescribing is considered to be inappropriate" (Eudaley et al., 2019, p. 579). Furthermore research states that " we also saw an increase in guideline directed antibiotic duration accuracy of diagnosis coding improved, and rates of urine culture for cystitis were reduced. Changes to clinical workflow, including nursing staff activation of the CDS tool for any patient with symptoms of UTI, are expected to increase CDS tool utilization moving forward". (Eudaley et al., 2019, p. 585).
Learn more about chronic illnesses:
References:
YouTube. (n.d.). https://youtube.com/shorts/bYfdJDygKLQ?feature=shared
De Vries, S., Doesschate, T. T., Totté, J. E., Heutz, J. W., Loeffen, Y. G., Oosterheert, J. J., Thierens, D., & Boel, E. (2022). A semi-supervised decision support system to facilitate antibiotic stewardship for urinary tract infections. Computers in Biology and Medicine, 146, 105621. https://doi.org/10.1016/j.compbiomed.2022.105621
Eudaley, S. T., Mihm, A. E., Higdon, R., Jeter, J., & Chamberlin, S. M. (2019). Development and implementation of a clinical decision support tool for treatment of uncomplicated urinary tract infections in a family medicine resident clinic. Journal of the American Pharmacists Association, 59(4), 579–585. https://doi.org/10.1016/j.japh.2019.03.006
Goebel, M. C., Trautner, B. W., & Grigoryan, L. (2021). The five DS of Outpatient antibiotic Stewardship for Urinary tract Infections. Clinical Microbiology Reviews, 34(4). https://doi.org/10.1128/cmr.00003-20
TEDx Talks. (2024, October 21). How AI can heal healthcare | Edmund Jackson | TEDxNashville [Video]. YouTube. https://www.youtube.com/watch?v=7ZsyYCZB3Nw
Urinary tract infections. (2025, February 7). Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/9135-urinary-tract-infections
Case Study: Interdisciplinary Approach to Managing Chronic Urinary Tract Infections (UTI's) in Primary Care
Patient Background:
Name: Mary Thompson
Age: 68
Gender: Female
Medical History: Type 2 diabetes, hypertension, recurrent urinary tract infections (UTIs) (6 episodes in the past year)
Medications: Metformin, Lisinopril, Aspirin 81 mg, Nitrofurantoin (prophylactic)
Presentation:
Mary Jones, a 68-year-old Caucasian female, presents to the clinic with complaints of urinary urgency, burning sensation, and lower abdominal discomfort for the past three days. She reports a history of recurrent UTIs despite multiple courses of antibiotics. She follows proper hygiene, stays hydrated, and has tried cranberry supplements but continues to experience frequent infections.
Clinical Findings:
Vital Signs: BP 138/82 mmHg, HR 78 bpm, Temp 99.2°F, RR 16, SpO2 98% on room air
Physical Exam: Mild suprapubic tenderness, no CVA.
Urinalysis: Positive for leukocyte esterase, nitrites, WBCs >100/HPF
Urine Culture: Pending
Setting:
Primary Care Clinic in a urban upstate NY area.
Challenge: Antibiotic Resistance due to Frequent UTI Treatment
Solution: Develop and Utilize a Antibiotic Stewardship and Alternative Prevention Strategies for Urinary Tract Infections.
How can AI heal healthcare ? 👍
Interdisciplinary Team:
Family Nurse Practitioner
Conducts patient assessment and order diagnostic tests
initiates empirical antibiotic therapy while awaiting culture results
Refers the patient to specialists for further evaluation
Provide patient education on UTI prevention and self care strategies.
Physician
Collaborates with the FNP to manage complex cases
Review lab results and recommends further diagnostic imaging if needed
Assists in escalating care if the patient's conditions worsens (ER, Urgent Care)
Medical Assistants
Collaborates with the FNP to manage complex cases
Review lab results and recommends further diagnostic imaging if needed
Assists in escalating care if the patient's conditions worsens (ER, Urgent Care)
Provide patient handouts on hygiene and preventive care
Nurses
Administer medications if prescribed ( IV antibiotics in severe cases)
Provide education on prescribed medication and why it was prescribed for the patient
Educate the patient on proper medication use and hydration
Ensure follow-up appointments are scheduled with specialists
Infectious Disease Specialist
Reviews urine culture results to ensure appropriate antibiotic selection
Assesses the possibility of antibiotic resistance due to frequent infections
Recommends antibiotic stewardship strategies to reduce unnecessary antibiotic use
Urologists
Evaluates for underlying structural abnormalities or bladder dysfunction that may contribute to recurrent infections
Orders necessary imaging (Ultrasound or cystoscopy) if needed.
Discusses alternative treatment options such as low-dose prophylactic antibiotics or vaginal estrogen therapy
Pharmacist
Reviews current medications to assess potential problems or interactions
Educates patient on proper antibiotic use and adherence
Provides recommendations for non-antibiotic preventive strategies
Nutritionist
Advises on dietary changes that may support Urinary Tract health
Discuss the use of probiotics in maintaining a healthy urinary microbiome
Care Coordinator/ Case Management
Provide community resources
coordinate ongoing educational and support
Manages medications and patient adherence
Coordinates follow up appointments with specialists
CDS System Design and Implementation:
Needs Assessment: Identify gaps in current process of chronic UTI's in patients in the primary care setting. Evaluate: Inconsistent ABX stewardship, lack of standardized Prevention and Delayed Identification of Chronic UTI's and no streamline process for patient to be referred to a specialists.
Data Elements: EHR to trigger alerts and provide decision support for providers. For example: Patient demographics, medical history, medication history and lab data.
Algorithm Development: Rule bases algorithm to provide clinical decision making for chronic UTI management.
CDS Algorithm Workflow:
1. Patient Identification:
A UTI risk score is generated based on recurrence history (>3 UTIs in 12 months) and risk factors.
An alert is triggered in the EHR if a patient meets criteria for chronic UTI.
2. Diagnostic Guidance:
The system recommends urinalysis and urine culture before antibiotic prescription.
It flags possible antibiotic resistance based on past culture results.
3. Treatment Recommendations:
The CDS suggests first-line antibiotics based on local resistance data.
If recurrence is high, it recommends infectious disease consultation.
Non-antibiotic options (e.g., vaginal estrogen for postmenopausal women, probiotics) appear as decision prompts.
4. Referral & Follow-Up:
If high-risk factors are detected, an automatic referral suggestion to a urologist or infectious disease specialist appears.
The system sends follow-up reminders to patients via the patient portal
5. EHR Integration: Must support different level of providers workflow
Automated alerts: flag patients with recurrent UTI's and antibiotic resistance directly in the patient chart
Pre-populated order sets with UA's, Urine Cultures and recommended antibiotics
Provider support popups- Non intrusive alerts providing real time recommendations for UTI prevention and antibiotic choice.
Referral link built in within the EHR system to continue patient care beyond the primary care office
Utilization of patient engagement tools such as patient portals and application for prevention strategies.
6. Training and Education to Implement CDS
FNP
Focus on cup to date clinical guidelines for chronic UTI management, CDS navigation.
Hands on EHR demos, case based training
Physicians
Review of antibiotic stewardship strategies, CDS alert interpretation training.
CME session and grand rounds weekly.
Nurses, Case Managers and MA's
Review proper urine collection process without contaminating specimen
Identify high risk patients from triage to providers
Roel playing, manuals and workflow trainings.
Review proper urine collection process without contaminating specimen
Identify high risk patients from triage to providers
Roel playing, manuals and workflow trainings.
Pharmacists
Antibiotic Stewardship training, synthesize culture dats and counsel patients on prevention at medication dispensing
Team workshops
IT Specialists
Troubleshoot system
ensure EHR go live date run smooth
Point of contact for technical training sessions and information
Evaluation:
After implementation of this CDS system, there was a 30 % decrease in UTI related visits to the primary care clinic over 6 months.
There was a 45% increase in non - antibiotic use interventions (probiotics, vaginal estrogen's and nutritional counseling).
There was a 25% decrease in unnecessary antibiotic prescriptions through the utilization of the antibiotic stewardship
Faster referral process with use of the CDS system through the EHR and cut down wait time by 15% overall.
Results:
Cut down on waiting time to be seen in office
Less patients returning or being admitted to hospital for complication reoccurring UTI's
There are now monthly provider feedback sessions
Patient satisfaction scores are up after implementation of CDS system
IT Specialists are leading staff feedback session monthly
What other studies say about the implementation of CDS systems for UTI prediction:
" The system provides the clinician with this prediction at an earlier stage in the diagnostic process. This enables the clinician to withhold the administration antibiotics, to look for other causes of infection or to recognize asymptomatic bacteriuria in case no UTI is predicted. In an exploratory analysis, we combine the predictive performance of the CDSS as a whole with an analysis of antibiotic prescriptions surrounding urine cultures to provide an estimate of the potential impact the system might have on prevention of inappropriate prescription of antibiotics. We calculated that the use of the system could result in a reduction of antibiotic prescriptions of up to 15.2% for the target population in our setting, although this number is expected be lower in clinical practice." ( De Vries et al., 2022, p. 13).
Conclusion:
This CDS System improves treatment, patient safety and enhances teamwork within the interdisciplinary network identified. Through utilization of an antibiotic stewardship, algorithms, support data pop-ups in the EHR and use of patient friendly applications, this ensures patients are being treated appropriately based on real time data. This system would allow for better patients outcomes while reducing the UTI recurrence and antibiotic resistance. "Available evidence suggests overuse of antibiotics contributes significantly to development and spread of resistance, and approximately 50% of outpatient antibiotic prescribing is considered to be inappropriate" (Eudaley et al., 2019, p. 579). Furthermore research states that " we also saw an increase in guideline directed antibiotic duration accuracy of diagnosis coding improved, and rates of urine culture for cystitis were reduced. Changes to clinical workflow, including nursing staff activation of the CDS tool for any patient with symptoms of UTI, are expected to increase CDS tool utilization moving forward". (Eudaley et al., 2019, p. 585).
Learn more about chronic illnesses:
References:
YouTube. (n.d.). https://youtube.com/shorts/bYfdJDygKLQ?feature=shared
De Vries, S., Doesschate, T. T., Totté, J. E., Heutz, J. W., Loeffen, Y. G., Oosterheert, J. J., Thierens, D., & Boel, E. (2022). A semi-supervised decision support system to facilitate antibiotic stewardship for urinary tract infections. Computers in Biology and Medicine, 146, 105621. https://doi.org/10.1016/j.compbiomed.2022.105621
Eudaley, S. T., Mihm, A. E., Higdon, R., Jeter, J., & Chamberlin, S. M. (2019). Development and implementation of a clinical decision support tool for treatment of uncomplicated urinary tract infections in a family medicine resident clinic. Journal of the American Pharmacists Association, 59(4), 579–585. https://doi.org/10.1016/j.japh.2019.03.006
Goebel, M. C., Trautner, B. W., & Grigoryan, L. (2021). The five DS of Outpatient antibiotic Stewardship for Urinary tract Infections. Clinical Microbiology Reviews, 34(4). https://doi.org/10.1128/cmr.00003-20
TEDx Talks. (2018, May 29). How I cured myself of chronic illness and reversed ageing | Darryl D’Souza | TEDxPanaji [Video]. YouTube. https://www.youtube.com/watch?v=kv1UT1byFbE
Urinary tract infections. (2025, February 7). Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/9135-urinary-tract-infections
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