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PICO Question

Presented to

Dr. Brandburg, Gloria PhD, RN, GNP-BC

By

Onwukwe, Lauretta

THE UNIVERSITY OF TEXAS

SCHOOL OF NURSING AT GALVESTON

_____________________

In Partial Fulfillment

Of the Requirements for the Course

GRNS 5634 Adult-Gerontologic Nurse Practitioner Practice I: Healthy Adults

______________________

October 07, 2012

PICO QUESTION

In female patients with urinary tract infection (UTI), is treating them with nitrofurantoin more effective than trimethoprim-sulfamethoxazole (Bactrim)?

In this era of the 21st century, nursing care is rooted on evidence-based practice. Evidence based practice is the use of the best scientific evidence to support the clinical decision making. The identification of the best evidence requires the construction of an appropriate research question and review of the literature. This paper will concisely review the concept of PICO model, formulation of PICO question and the clinical problem, and what is learned from the PICO question. PICO is mnemonic for Patient, Intervention, Comparison and Outcome. (Moyer, 2008).

A PICO question identifies the key problem of the patient (P), what treatment you are considering for the patient (I), alternative treatment being considered(C), and what will be the outcome (O). Most health care agencies strive to include evidence –based practice in their routine care. This involves evaluation and implementation of published research in nursing care. Research has become the norm of the day which nurses and other professionals employ to justify the existing practice or to search for better alternatives. The formulation of a researchable question that can be likely answered is the first step in evidence- based research and PICO is of great significance. The PICO model helps to construct research questions that can be originated from the clinical practice or from any other professional fields. The objective of PICO is to find answers to clinical questions for evidence-based practice. It helps to formulate good searchable clinical questions, clarify questions, and makes them easy to be answered. Additionally, PICO is used to generate terms which are essential in literature search for the current best evidence. (Moyer, 2008) The strategy of PICO will be utilized to answer my clinical experience question of why nitrofurantoin is chosen over trimethoprim-sulfamethoxazole (Bactrim) antibiotics in the treatment of adult female patients with urinary tract infection (UTI) that present to the clinic.

A urinary tract infection (UTI) is a bacterial infection that affects the urinary tract. The urinary tract comprises the urethra, bladder, ureters, or the kidneys. The most common cause of UTI is Escherichia coli but other microbes like fungi, parasites can cause UTI. When it affects the lower urinary tract, it is known as cystitis (a bladder infection), and when it affects the upper urinary tract, it is known as pyelonephritis (a kidney infection). (Davis, 2012)

In my clinical setting, most of the female patients present with urinary tract infection (UTI). Antibiotics are the treatment regimen for UTI and my preceptor would always ask for the preferred antibiotic. Having had clinical experience in which nitrofurantoin is used in treating UTI; my recommended antibiotic is always nitrofurantoin. Although, in agreement with me, my preceptor would ask why nitrofurantoin is chosen over other antibiotics such as bactrim? Hence, I deemed it necessary to carry out research on the effectiveness of nitrofurantoin and bactrim in the treatment of UTI. To come up with a researchable question, I utilized PICO strategy to formulate a question thus: In female patients with urinary tract infection (UTI), is treating them with nitrofurantoin more effective than trimethoprim-sulfamethoxazole (Bactrim)?

Urinary tract infection (UTI) is the most common bacterial infection among adult women. It accounts for an estimated 7million outpatient office visits annually, with an estimated cost of 1.6 billion dollar (Goroll, & Mulley, 2009, Pg.947). In 1995, 10.8 percent of women in the United States from 18 years of age or older had suffered from UTI resulting in 11.3 million antibiotics prescriptions (McKinnell, Stollenwerk, Jung, & Miller, 2011). Treatment failure of uncomplicated UTI due to drug resistance and poor choice of antibiotics will lead to serious consequences. Such consequences may include development of pyelonephritis, repeat office visit, hospitalization, and financial expenditure. Because of the aforementioned, it is very important to tailor the goal of therapy towards the prevention of infection which involves the use of antibiotics. It is very pertinent to know the rationale behind the choice of a particular antibiotic over another. For the purpose of this paper, the effectiveness of only two antibiotics; nitrofurantoin and trimethoprim-sulfamethoxazole (Bactrim) will be reviewed. Both antibiotics are being utilized in the treatment of UTI.

There has been an increase in the resistance of uropathogens to antibiotics. Consequently, the treatment of UTI has become difficult. To achieve the goal of UTI treatment, it is very imperative to choose antibiotics that are susceptible to bacteria. Although trimethoprim-sulfamethoxazole and fluoroquinolone are considered the first drug of choice for uncomplicated UTI, but they have high incidence of resistance.(Goroll, & Mulley, 2009, Pg951). According to Amabile-Cuevas (2011), “the treatment of urinary tract infections (UTIs) is increasingly difficult due to the rising resistance of uropathogens towards commonly used antimicrobials, such as sulphonamides, quinolones and even third-generation cephalosporins.” The consequences of drug resistance are treatment failures and this is why it is significantly important to use an antibiotic with the most resistance as the drug of choice. Most of the reviewed articles agree on the fact that nitrofurantoin has high resistance when compared with other antibiotics. Nitrofurantoin is known to be very effective for non-complicated cystitis with very low resistance prevalence, even in countries where resistance to other drugs is rather high. There has been a concern with regard to nitrofurantoin compliance due to four times a day dosing requirement, but according to Amabile-Cuevas (2011), three times a day doses are as effective in the treatment of UTI as four doses a day. This will increase compliance and nitrofurantoin will be more acceptable to health care providers and patients, and ultimately decreases the use of broad spectrum antibiotics that promote resistance. In the same vein, Cunha, Schoch, & Hage (2011) affirmed that “among susceptible uropathogens after extensive use worldwide for more than 50 years, there has been virtually no acquired resistance to nitrofurantoin."

One of the advantages of Nitrofurantoin is that it works against most species of multidrug-resistant gram-negative bacilli in addition to wide spectrum b lactamase-strains and vancomycin-resistant enterococci (VRE). Trimethoprim-sulfamethoxazole (TMP-SMX) is not effective in the treatment of UTI due to VRE which has high resistance potential. A research study shows that nitrofurantoin is cost-minimizing when the percentage of Trimethoprim-sulfamethoxazole (TMP-SMX) resistance to e coli is greater than 17 percent (McKinnell, Stollenwerk, Jung, & Miller, 2011). Great attention should be paid to the side effects of Trimethoprim-sulfamethoxazole (TMP-SMX). Amongst such side effects are interstitial nephritis, hyperkalemia, and acute tubular necrosis (Fraser, Avellaneda, Graviss, & Musher 2012).

Quality health care service involves implementation of evidence- based practice. Research is pivotal in answering questions with regards to the best way of providing care for patients. This underscores the need to formulate a good researchable question and have knowledge of PICO strategy for effective treatment outcomes. Prevalence of UTI and antibiotics resistance is consequential to treatment failure, frequent physician visit, and hospitalization. Hence it is very important for health care providers especially us, potential Nurse Practitioners to have an in-depth knowledge of the effectiveness of antibiotics in the treatment of infections and their potential for resistance. The right choice of antibiotic will prevent treatment failure and enhance quality of life of patients.

References:

Amabile-Cuevas, C.F. (2011) Antimicrobial activity data in support of nitrofurantoin three times

per day. Retrieved from



Cunha, B.A, Schoch P.E, & Hage, J.R (2011). Nitrofurantoin: Preferred Empiric Therapy for

Community-Acquired Lower Urinary Tract Infections. Retrieved from

.

Davis, C.P. (2012).Urinary tract infection. Retrieved from



Fraser, T.N, Avellaneda, A.A, Graviss, E.A, & Musher, D.M.(2012). Acute kidney injury

associated with trimethoprim/sulfamethoxazole. Retrieved from



Goroll, A.H, & Mulley, A. G. (2009) Primary Care Medicine: office evaluation and management

of the adult patient. (6th ed) Philadelphia: Pennsylvania. Lippincott Williams &Wilkins

Jacob, S. (2009) Searching strategies: framing the question (PICO). Retrieved from



McKinnell, J.A, Stollenwerk, N.S, Jung, C.W, & Miller, L.G (2011) Nitrofurantoin compares

favorably to recommended agents as empirical treatment of uncomplicated urinary tract

infections in decision and cost analysis. Retrieved from



19&sid=512eac65-c3f4-4db9-b8d1-208bb15d9c50%40sessionmgr13.

Moyer, V. (2008) Weighing the Evidence: PICO Questions: what are they,

and why bother? Retrieved from



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