Keywords urinary tract infections - pregnancy - medical education - medical informatics application
Palavras-chave infecções do trato urinário - gestação - educação médica - aplicações de informática
médica
Introduction
The current scenario, driven by technological innovations, has enabled health professionals
to have immediate access to up-to-date information that supports medical decision-making.[1 ]
[2 ]
[3 ] Mobile applications are frequently used in daily clinical practice (such as, Medscape,
Epocrates and UpToDate). However, the information is often extensive and lacking objectivity,
and its applicability in different locations is debatable.[1 ]
[4 ] This situation is particularly noticeable when considering the choice of antimicrobials
for the treatment of infectious diseases.
Treatment protocols for urinary tract infection during pregnancy are scarce in the
medical literature, and recommendations can vary regionally according to the local
microbiota, with different antimicrobial resistance patterns.[5 ]
[6 ] Therefore, knowledge and ready access to up-to-date information on this subject
are fundamental for the diagnosis and treatment to prevent maternal-fetal complications,
such as maternal sepsis, premature birth, and low birth weight.[5 ]
[7 ]
[8 ]
The present study aimed to analyze the prescription of antimicrobial agents for pregnant
women admitted to the Obstetrics Service of a reference hospital in the care of women
in southern Brazil who presented a clinical case compatible with acute pyelonephritis.
This analysis was performed before and after the promotion of an institutional protocol
for the treatment of pyelonephritis during pregnancy, and on a third occasion after
the introduction of a mobile educational tool for use with a smartphone, which provided
guidelines for the diagnosis and treatment of pyelonephritis in pregnancy.
Methods
A retrospective study was conducted to evaluate antimicrobial prescriptions given
on admission to pregnant patients diagnosed with acute pyelonephritis. The evaluation
took place over 3 different periods (2010, 2013 and 2015) at the Hospital Fêmina,
in Porto Alegre, in the state of Rio Grande do Sul, Brazil. The hospital has an obstetric
center, a surgical block, an adult intensive care unit (ICU), and a neonatal ICU,
with 180 available beds. Hospital procedure requires the review of all antimicrobial
prescriptions by an infectious disease physician from the Infection Control Service
of the Hospital Fêmina.
For the purposes of the present research, the prescriptions given to pregnant women
diagnosed with pyelonephritis were evaluated at 3 different points in time: 1) before
the implementation of the institutional protocol for the diagnosis and treatment of
pyelonephritis during pregnancy—data collected from June 2010 to December 2010; 2)
after the implementation and dissemination of the institutional protocol for the diagnosis
and treatment of pyelonephritis during pregnancy, which occurred in January 2011—data
collected from January 2013 to December 2013; 3) after the implementation and dissemination
of a smartphone application with objective and summarized data for the treatment of
pyelonephritis during pregnancy, which occurred in December 2014—data collected from
January 2015 to November 2015.
The diagnosis and treatment protocol for pyelonephritis during pregnancy was produced
by the Hospital Infection Control Service and the Obstetrics Service of the Hospital
Fêmina in January 2011. It was distributed via email to all doctors over the course
of 2011 and 2012, and was made available on the prescription system to enable a quick
and easy access. The protocol contains microbiology data for patients admitted to
the hospital in 2010 and recommendations regarding diagnosis and antimicrobial therapy
for pyelonephritis during pregnancy, with the first treatment choice being the intravenous
(IV) administration of cefuroxime (0.75–1.5 g every 8 hours). The IV administration
of a combination of amoxicillin (1 g) with clavulanate (0.2 g) every 8 hours, is suggested
as an alternative. The same protocol recommends avoiding the use of oral β-lactams
due to their ineffectiveness, as well as of drugs with a low susceptibility profile
in isolated urine culture exams, such as ampicillin, cephalothin, and sulfamethoxazole/trimethoprim.[9 ] Due to inadequate tissue levels, nitrofurantoin and fosfomycin are considered inappropriate
for the treatment of pyelonephritis.
The ATB Fêmina smartphone application, available for iOS and Android platforms ([Fig. 1 ]), is a Portuguese language app, developed by the Hospital Infection Control Service
of the Fêmina Hospital to facilitate quick access to objective data, with information
regarding the diagnosis of infectious diseases during pregnancy and the appropriate
specific treatment. The application was widely circulated to all the prescribing health
professionals at the Hospital Fêmina, becoming extensively used by all. The information
was based on the current literature and local microbiology, with the same recommendations
for the treatment of pyelonephritis in pregnant women as was established by the protocol
in 2011.[5 ]
[6 ]
[7 ]
[8 ]
Fig. 1 Layout of ATB Femina mobile application .
The authors compared the prescriptions issued by physicians upon the admission of
pregnant women with pyelonephritis for each of the three time periods, in relation
to the following variables: type of antimicrobial prescribed; dose; interval; and
route of administration. A fifth variable was considered in accordance with the four
aforementioned items, meaning that if all protocol steps were properly followed, the
prescription was considered appropriate. This was designated as being completely appropriate . The cases in which there were one or more inconsistencies in the prescription were
considered as inappropriate.
The categorical variables for the statistical analysis were described by frequencies
and percentages. The chi-squared test was used to compare the frequency of satisfactory
prescriptions. The analysis was performed with IBM SPSS Statistics for Windows, Version
20.0 (IBM Corp., Armonk, NY, USA), considering a significance level of 5%.
The present study was approved by the Research Ethics Committee of the Grupo Hospitalar
Conceição on November 27th, 2015, under the registration number 50047715.9.0000.5530.
Results
The prescribing physicians did not vary over the 3 periods evaluated (2010, 2013,
and 2015), with 76% of the prescribers working in the 3 periods, as presented in [Fig. 2 ].
Fig. 2 Venn diagram about the variation of gynecology and obstetrics practitioners during
the study.
In the first evaluation period, from July to December 2010, there were 99 cases of
acute pyelonephritis during pregnancy. A total of 73 cases (73.7%) received cefuroxime
0.75 g IV three times daily, and one patient received 1.5 g IV three times daily.
In 6 cases, cefuroxime was prescribed with an inadequate interval of four times daily
(4%). One patient received ampicillin 2 g + sulbactam 1 g IV 3 times daily. A total
of 14 cases (14.1%) were prescribed ampicillin 1 g IV, with 1 having an inappropriate
interval of 3 times daily. Two patients were prescribed piperacillin/tazobactam 4.5 g
IV 3 times daily; 1 patient took ciprofloxacin 0.5 g IV twice daily. In 2 cases, cefuroxime
was administered orally 0.5 g twice daily; and in 1 case the oral administration interval
was inadequate, being prescribed 3 times daily.
In the second evaluation period, from January to December 2013, there were 116 cases
of acute pyelonephritis during pregnancy. A total of 104 patients (89.6%) received
a prescription of cefuroxime IV, and in 14 cases the prescription was for twice the
usual dose, which was 1.5 g 3 times daily. In 5 cases, (4.3%) cefuroxime IV 0.75 g
was prescribed inadequately, twice daily. One patient received piperacillin/tazobactam
4.5 g IV 3 times daily; 1 patient took cefepime 1 g IV every 3 hours; and 5 patients
(4.3%) received ampicillin 1 g IV 4 times daily.
In the final evaluation period, from January to December 2015, of the 107 cases admitted
with acute pyelonephritis during pregnancy, 103 (96.3%) received cefuroxime IV 3 times
daily, with 85 (82.5%) of these given a 0.75 g dosage, and 18 (17.5%) a 1.5 g dosage.
Two patients were started on piperacillin/tazobactam 4.5 g IV 3 times daily, and another
2 patients received cefepime 2 g twice daily. This last evaluation period showed no
inappropriate choice of antimicrobial, dosage, route, or interval of administration.
The evaluation of the prescribing physicians and of the adequacy of the prescriptions
between the different periods studied revealed a significant increase in appropriate
conduct for the choice of antimicrobial, route of administration, dosage, and interval,
as well as for the total number of interventions following the introduction of the
protocol, and again after the implementation of the software application, as shown
in [Table 1 ] and in [Fig. 3 ].
Fig. 3 Comparative analysis of appropriate prescriptions in the three periods studied.
Table 1
Descriptive table of the “proper conduct” frequency in the prescriptions
2010
2013
2015
p -value
Antimicrobial agent
83.8
95.7
100.0
< 0.001
Dosage
100.0
100.0
100.0
1.000
Route of administration
97.0
100.0
100.0
0.018
Interval between doses
91.9
95.7
100.0
0.004
Completely appropriate prescription
74.7
91.4
100.0
< 0.001
Data presented in percentages (%) and compared by the trend chi-squared test.
Discussion
The present study described the impact of the inclusion of auxiliary tools on the
prescription of antimicrobials by physicians in a maternal-infant hospital, a reference
center in the care of pregnant women in the state of Rio Grande do Sul, Brazil. The
use of mobile applications in clinical decision making, prescriptions, and for accessing
medical information has grown rapidly in recent years, and it is estimated that > 80%
of the prescribing professionals have smartphones.[10 ]
[11 ]
[12 ] However, the scarcity of clinically relevant applications on smartphone search platforms
and the lack of innovative and original information hinders the dissemination of specialized
medical knowledge.[11 ]
[12 ]
[13 ]
The development of the protocol in 2011 and the subsequent creation of a smartphone
application containing and objectively summarizing the contents of the protocol were
achieved, and they could be made available to all physicians at the Hospital Fêmina.
In addition, following the 2011 implementation of the treatment protocol for pyelonephritis
in pregnancy and the use of the mobile app, a simultaneous and statistically significant
increase in the quality of antimicrobial therapy prescription for pregnant women admitted
to the hospital with pyelonephritis was observed, from 75% in 2010 to 100% in 2015.
The number of cases included in the present study, the fact that it was conducted
in only one hospital, and the possibility that the improvement in prescriptions could
have occurred secondarily to the major interest in this subject could be seen as limitations
of the present study. Nonetheless, it should be noted that the group of doctors involved
in the prescriptions has not varied significantly in the three periods of observation.
This is, however, the first study that aimed to evaluate the effect of the use of
a specific mobile application on the treatment of infectious diseases during pregnancy,
in relation to the quality of prescriptions of antimicrobial agents. Finally, our
study has demonstrated that there was a significant improvement in the prescriptions
for the treatment of acute pyelonephritis in pregnancy after the inclusion of the
protocol and the use of the application.
Smartphone applications that support clinical practice are especially important for
physicians as they can provide quick access to information that is consistent with
contemporary scientific evidence all over the world.[14 ]
[15 ]
Conclusion
The present study demonstrates that the design and use of smartphone applications
should be encouraged to attain a better quality and accuracy in prescriptions and
to include strategies that not only reduce the risk of negative outcomes, but also
improve the quality of care and treatment for maintaining the health of both the mother
and the baby.
