Infectious Diseases Now 53 (2023) 104707

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Original Article

Descriptive management of suspected acute cystitis in adult patients by

French general practitioners during remote consultation
Alexandra Jollivet a,⇑, E. Caruana b, J. Salomon c, L. Rodriguez d, D. Boutoille e
a
10 Rue de l’ile de Port Cros 44980, Sainte Luce sur Loire, France
b
Cabinet de Médecine Générale, 56 Rue Charles Rivière, 44400 Rezé, 75008 Paris, France
c
Pédiatre MD, PhD, Directrice Médicale Adjointe Qare, Référente Médicale Formation et Qualité, 36, Avenue Pierre 1er de Serbie, 75008 Paris, France
d
Infirmier Support et Formation Qare. 36 Avenue Pierre 1er de Serbie, France
e
Infectiologue CHU de Nantes, CHU de Nantes, 1 Place Alexis Ricordeau 44093, Nantes, France

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: The main objective of this study was to analyze French general practitioners’ (GP) online pre-
Received 9 November 2022 scriptions for suspected acute cystitis using a single nationwide teleconsultation platform.
Revised 15 March 2023 Patients and Methods: First, a descriptive study of management for suspected cystitis was conducted from
Accepted 1 April 2023
the 1st of January to the 31st of December 2020. After which, following pedagogical intervention, a pre/-
Available online 11 April 2023
post descriptive analysis of the antibiotics prescribed was carried out.
Results: Some 496,041 teleconsultations (TCs) were carried out in 2020 on the Qare platform. Among
Keywords:
them, 15,089 TCs for cystitis with ICD-10 encoding (N30) were analyzed. Fosfomycin trometamol was
Antibiotic
Cystitis
the most prescribed antibiotic (n = 10297, 69%), while fluoroquinolones (n = 1568, 10.6%) were the sec-
Remote consultation ond. Urine test strip was prescribed in 3157 (20%) and urine culture in 7033 (47%) of the TCs. July-August
Urinalysis 2020 and July-August 2021 were compared and while a significant drop in fluoroquinolone prescriptions
and a major increase in Fosfomycin trometamol were observed, there was no change in the prescriptions
of urine culture. An average antibiotic conformity rate of 61.5% was observed before the intervention, and
68.8% afterwards.
Conclusions: Cystitis is a recurrent reason for remote consultation. The study demonstrated sizable over-
prescription of urine culture, ultrasound, and fluoroquinolones. Intervention should be improved and
strengthened to guarantee continuous training and awareness of GP’s on appropriate cystitis prescrip-
tions in telemedicine.

1. Introduction
Telemedicine has been defined by the World Health Organiza-
tion (WHO) as ‘‘the practice of medicine using interactive data
communication techniques, including consultation, diagnosis and
treatment, as well as training and transfer of medical data” [1].
There exist five acts of telemedicine [2]: teleconsultation (TC),
tele-expertise, remote medical monitoring, remote medical assis-
tance, and medical regulation. In France any patient, if this mode
of examination is suitable for his or her condition, can benefit from
reimbursed teleconsultation, in compliance with the coordinated
care pathway offered by French health insurance. Under the aegis
of the recommendations of the Regional Health Agency (ARS, in
French) and the National Council of the Order of Physicians (CNOM,
in French), various certified telemedicine platforms have been
developed. Some of them emerged through private partnerships,
⇑ Corresponding author.
E-mail address: jollivet.alexandra@gmail.com (A. Jollivet).
such as QareÒ, which was one of the first to be launched in France.
To date, Qare includes close to 1600 health professionals, of whom
870 are general practitioners.
Use of teleconsultation significantly increased in the context of
the COVID-19 pandemic [3]. The French health insurance company
recorded 5.5 million teleconsultations between March and April
2020, more than 80% of which were performed by general practi-
tioners [4]. In addition, 2.5 million teleconsultation appointments
were made on the DoctolibÒ platform (French medical appoint-
ment website) from the onset of the epidemic to the end of April
2020 [4]. The regional union of private health professionals (URPS,
in French) in the Paris area surveyed more than 1700 doctors rep-
resentative of the local medical population [5]; for 70%, teleconsul-
tation has become an established practice. This contrasts with the
reluctance shown by physicians in previous studies on teleconsul-
tation [6,7].
Acute cystitis is a frequent reason for consultation in general
practice in France (1 to 2% of consultations according to studies
conducted between 2007 and 2009) [8,9]. It is also a frequent rea-

https://doi.org/10.1016/j.idnow.2023.104707
2666-9919/Ó 2023 Elsevier Masson SAS. All rights reserved.
A. Jollivet, E. Caruana, J. Salomon et al.
son for teleconsultation, and in 2020 it was the third most common
on the QareÒ platform (representing 3% of the TC). National recom-
mendations for the management of cystitis were first established
in 2008 [10], before being modified in 2015 [11] and updated in
2018 and 2021 [12,13,14]. Positive diagnosis is based on functional
urinary signs, and may (or may not) be associated with fever or
back pain. In uncomplicated acute cystitis, the recommended strat-
egy is probabilistic antibiotic therapy guided by the urine test strip,
with Fosfomycin-trometamol as first-line, and pivmecillinam as
second-line treatment. In cystitis at risk of complication, which is
the defined by the presence of at least one risk factor for complica-
tion (any anomaly of the urinary tract, pregnancy, frail elderly sub-
ject, chronic renal insufficiency, severe immunodepression),
urinalysis by microscopy and culture is systematically recom-
mended. Whenever possible, it is advisable to postpone antibiotic
therapy to ensure that the treatment is adapted to the antibiogram.
If antibiotic therapy cannot be deferred, first-line treatment is
nitrofurantoin, followed by fosfomycin-trometamol as second-
line treatment. Cystitis is considered as recurrent if it occurs at
least three times a year or twice within the previous six months
[11].
The main objective of this study was to describe the manage-
ment of suspected acute cystitis in the framework of teleconsulta-
tion, on a certified French national open access platform. The
secondary objective was to compare conformity of antibiotic pre-
scription following a short educational intervention on the proper
use of antibiotics.
2. Methods
This study of professional practices by means of descriptive
non-inferential retrospective analysis, was based on the extraction
of automated and anonymized data from teleconsultations in a
computerized medical record. The study was carried out over a
period covering 2020. We analyzed all teleconsultations with the
ICD-10 code N30 and a structured prescription on the platform.
An educational intervention was carried out during the week of
21–28 June 2021. Data analysis was then carried out in July and
August 2021 so as to measure the impact of the intervention on
prescriptions.
2.1. Location of the study
The study was carried out on QareÒ, a certified open access
French teleconsultation platform, accessible through smartphone
or computer.
2.2. Inclusion criteria
All adult female patients having used the platform for telecon-
sultation with a diagnosis of suspected acute cystitis were included
(according to the International Classification of Diseases 10). The
suspected diagnosis was based on their answers to physicians’
questions. All men were excluded (they manage cystitis differ-
ently), as were all patients under 18.
2.3. Analysis
The following variables were analyzed: type of cystitis (uncom-
plicated, at risk of complication, recurrent), month of teleconsulta-
tion, number of teleconsultations per patient for the same episode
of cystitis, patient age, names of the prescribed antibiotics, pre-
scription of urinalysis (urinary test strip and/or culture), other bio-
logical tests, imaging, other prescriptions (certificate of work
stoppage, preventive advice, hygienic and dietary measures). A
2
Infectious Diseases Now 53 (2023) 104707
member of the platform carried out data extraction that gave
access to anonymized data automatically available via a prescrip-
tion tool installed in the software. Data otherwise joined to patient
files were not accessible. An educational intervention for physi-
cians using the platform was planned based on a webinar, a card
summarizing the latest published recommendations [11,12], and
a short version of the first study results that was sent once a week
over two months. Additional data extraction was carried out in July
and August 2021, with a pre/post analysis comparing antibiotic
conformity with the same period in 2020. A prescription was con-
sidered compliant if the antibiotics corresponded to French recom-
mendations; in the event of suspected cystitis at risk of
complication, conformity attribution took into account a situation
when treatment could not be delayed [10].
Within the framework of the evaluation of professional prac-
tices based on anonymized data, in full compliance with the Jardé
law on biomedical research, no authorization request was
addressed to the French regulatory authority for data privacy
(CNIL, Commission Nationale Informatique & Libertés). In order
to use the data, a transfer agreement between the QareÒ platform
and the University Hospital of Nantes was concluded.
2.4. Statistical analysis of the data
The extracted anonymized data were downloaded into EXCEL
software. Descriptive statistics and analyses were analyzed using
the statistical software R 2.15.1 on a Mac OsX platform (R Founda-
tion for Statistical Computing, Vienna, Austria). We used the chi-
square test and Fisher’s t-test to perform the statistical tests. A
p-value of < 0.05 indicated a statistically significant difference,
which became highly significant if the p-value was < 0.001.
3. Results
Analysis of the 2020 data found that 15,492 out of 496,041 (3%)
teleconsultations on the platform presented a ICD-10 code ‘‘acute
cystitis” and a structured prescription, (only 11587, 75% of the
TC, were encoded using the ICD-10 encoding system). The popula-
tion was divided into 15,091 females (97.4%) and 397 males (2.6%),
with four patients excluded because of unknown gender. Two of
the females were excluded because they had an outlier age exceed-
ing 100 years. The physicians were general practitioners only; on
average, they had been certified in general medicine in 2006 and
were registered on the platform for more than 6 months. TC repre-
sented around 30% of their activity in a physical office.
Table 1 shows the overall characteristics of the data extracted
from the teleconsultations; average patient age was 36 years. An
antibiotic was prescribed in 14,860 (98.5%) of the analyzed tele-
consultations; two antibiotics together were prescribed in 294
(2%) cases. Regarding other prescriptions, analgesics were pre-
scribed in 3882 (26%) cases and antifungal medication in 705
(5%). A urinary dipstick was prescribed in 3157 (20.9%) teleconsul-
tations and a urine culture in 7033 (46.6%). Another complemen-
tary exam took place in 513 (3.4%) cases.
The number of teleconsulting females was 12,709 (out of the
15,089 TCs). In the same year, some patients repeatedly telecon-
sulted for cystitis, a result presented in Table 2.
An antibiotic was prescribed in 14,860 (98.5%) cases of sus-
pected acute cystitis. Table 3 shows the percentages of the differ-
ent antibiotics prescribed in the overall population, and for the
three different types of cystitis. Fosfomycin-trometamol was pre-
scribed 10,297 (69.3%) times, and was the most frequently pre-
scribed antibiotic with regard to all three types of cystitis:
10,111 (69.8%) for uncomplicated cystitis, 106 (34.7%) at risk of
complication and 80 (30.5%) in recurrent form. Fluoroquinolones
A. Jollivet, E. Caruana, J. Salomon et al. Infectious Diseases Now 53 (2023) 104707

Table 1
Overall characteristics of the data extracted from teleconsultations from 01/01/2020
to 31/12/2020, Qare telemedicine platform, France.
Values
Age (mean, SD)
< 65 (n, %)
65–75 (n, %)
> 75 (n, %)
Number of consultations / patient for acute cystitis (n, %)
1 Consultation
> 1 Consultation
Type of cystitis (n, %)
Uncomplicated
At risk of complication
Recurrent
First-line antibiotic therapy prescription (n, %)
Associated prescription antibiotic therapy (n, %)
Urinary test (n, %)
Urinary dipsticks
Urinary bacteriological analysis
were more frequently prescribed for suspected recurrent cystitis,
66 (25%), compared to around 10% for the other types. Pivmecilli-
nam was also more frequently prescribed [53 (20%)] in suspected
recurrent type. Nitrofurantoin was more frequently prescribed
[43 (12%)] in suspected cystitis at risk of complication,
In 294 (1.9%) teleconsultations, a second antibiotic was pre-
scribed in combination with the first. Fluoroquinolones were most
often prescribed in association in 87 cases (29.6%), followed by
pivmecillinam in 68 (23.1%), and cefixime in 54 (18.4%).
Culture was prescribed in 6987 (48%) cases of suspected
uncomplicated cystitis, in 210 (60%) cases of suspected cystitis at
risk of complication, and in 180 cases (69%) of suspected recurrent
cystitis. In cases where a urine culture was prescribed, i.e., 7033
(46.6%) teleconsultations, the most frequent antibiotic was
fosfomycin-trometamol, prescribed in 4246 (60%) cases, the sec-
ond was pivmecillinam in 867 TCs (12.3%) and third fluoro-
quinolones in 860 (12.2%) TCs (Table 4).
The analysis following the educational intervention spanned
July and August 2021, and was compared to the same period in
2020. In 2020, 3013 teleconsultations were analyzed (1343 in July,
1670 in August) and in 2021, 5854 teleconsultations were analyzed
(2867 in July, 2987 in August). Antibiotic therapy was prescribed in
2982 (99%) teleconsultations in 2020 and in 5738 (98%) cases in
Table 2
Number of teleconsultations per patient for suspected acute cystitis in teleconsul-
tation from 01/01/2020 to 31/12/2020, Qare telemedicine platform, France.
Number of teleconsultations per person (n, %) Overall sample (n = 15089)
1 10,892 (72.2)
2 2844 (18.9)
3 834 (5.5)
4 284 (1.9)
5 230 (1.5)
Table 4
Distribution of antibiotics prescribed in teleconsultation when a bacteriological
analysis (BA) had been prescribed. From 01/01/2020 to 31/12/2020, Qare telemedi-
cine platform, France.
Total
(n = 15089) Antibiotics (n, %) Prescribed BA (n = 7033)
36 (65) Fosfomycin-Trometamol 4246 (60.4)
14,703 (97.4) Pivmecillinam 867 (12.3)
290 (1.9) Fluoroquinolones 860 (12.2)
96 (0.6) Cefixime 488 (6.9)
Nitrofurantoin 187 (2.7)
10,892 (72.2)
4197 (27.8)
14,477 (95.9) 2021. Prescription conformity was assessed according to the rec-
350 (2.3) ommendations in effect at the time of the survey (Fig. 1). Disparity
262 (1.7) according to type of suspected cystitis was observed; conformity
14,860 (98.5)
was generally higher in the period after the intervention, especially
294 (1.9)
in case of suspected cystitis at risk of complication (51.3% versus
3157 (20.9) 39.7%) and in case of suspected recurrent cystitis (74.6% versus
7033 (46.6) 66%). For suspected uncomplicated cystitis, the respective rates
were similar (80.5% versus 79%). As for urine tests, a significant dif-
ference (p < 0.001) in the prescription of dipsticks was observed;
they were prescribed in 678 (23%) TCs in July and August 2020,
compared to 109 (2%) TC in July and August 2021. Concerning bac-
terial analysis, no significant difference in prescription was
observed, i.e., 1414 (47%) prescriptions in July and August 2020
and 2693 (46%) in July and August 2021 (p = 0.4). Fluoro-
quinolones, which were the third antibiotic prescribed, were less
prescribed, with a significant difference of 317 (10.5%) prescrip-
tions in 2020 versus 389 (6.6%) in 2021 (p < 0.001).
4. Discussion
In this retrospective study conducted from January to December
2020, a large number of teleconsultations (n = 15089, (3% of all TC))
for suspected acute cystitis were analyzed on the QareÒ platform
[9]. Teleconsultation has gradually developed and is particularly
suitable for young patients who are comfortable with recent tech-
nical tools. Only 386 patients (2.5%) were more than 65 years old;
this may be related to the low proportion of this type of cystitis
among older persons.
Concerning the management of acute cystitis, in comparison
with some other European countries [12,15,16,17], urinary dip-
sticks are less widely used in France, even though they are the only
widely recommended examination in case of suspicion of cystitis
[18,19,20], while several studies have shown that dipstick use
may reduce antibiotic prescription [12,13,21]. In our study, it
was prescribed in 3157 (20.9%) teleconsultations, which seems
consistent with previous data in French general practice France
[15,22]. In some other European Union countries, the urine dipstick
is more preponderant for example Denmark (98%) and Sweden
(93%) [16,17]. When comparing prescriptions given between
July-August 2020 and 2021, there was a significant decrease
(p < 0.001) in the prescription of urinary dipsticks. However, this
can be explained by technical changes in the prescription software
implemented independently of the study design. These changes

Table 3
Distribution of the prescribed molecules in teleconsultation from 01/01/2020 to 31/12/2020, Qare telemedicine platform, France.

Antibiotics (n, %) Overall sample Uncomplicated At risk of complication Recurrent

(n = 15089) (n = 14477) (n = 350) (n = 262)
Fosfomycin-Trometamol 10,297 (69.3) 10,111 (69.8) 106 (34.7) 80 (30.5)
Fluoroquinolones 1568 (10.6) 1472 (10.2) 43 (12.3) 66 (25.2)
Pivmecillinam 1567 (10) 1466 (10.1) 35 (10) 53 (20.2)
Cefixime 765 (5.1) 706 (4.9) 33 (9.4) 26 (9.9)
Nitrofurantoin 281 (1.9) 220 (1.5) 43 (12.3) 18 (6.9)

3
A. Jollivet, E. Caruana, J. Salomon et al.
Fig. 1. Antibiotic prescription compliance (nature of antibiotic), depending on the type of cystitis: uncomplicated cystitis, cystitis at risk of complication, and recurrent
cystitis.
were intended to better reference urine test strip variables, thereby
optimize its prescription on software, whereas previously its pre-
scription was made by text. This procedure may have substantially
reduced the number of urine strips prescribed.
During the observation period, 7033 (47%) urine cultures were
prescribed, often inappropriately in cases of suspected uncompli-
cated cystitis. While the global rate is comparable to the rates
found in previous studies in France [15,23], it remains high com-
pared to a more recent work [24]. In cases where such analysis
was prescribed, it was found that fosfomycin-trometamol
remained the first antibiotic prescribed and represented 4246
(60%) of the prescriptions. Pivmecillinam and fluoroquinolones
came second, with 867 (12.3%) and 860 (12.2%) prescriptions,
respectively. Finally, nitrofurantoin, which is the antibiotic therapy
recommended as a probabilistic treatment for cystitis at risk of
complication, came in 5th (187, 2.7%). In the analysis of July and
August 2021, there was no improvement in the prescriptions of
urine cultures (p = 0.4).
Regarding cystitis treatment, an antibiotic prescription was
found in 14,860 (98.5%) of the teleconsultations for acute cystitis.
This percentage is somewhat higher rate than in the Riquier study
(90%) [22]. A study conducted in Spain in 2010 found prescription
rates approximating 96% [25].
The recommendations for suspected uncomplicated acute cysti-
tis have gradually evolved over the years [10–12] with pivmecilli-
nam having become the second-line treatment and nitrofurantoin
and fluoroquinolones having been largely removed. In the present
study, there appeared to be good agreement regarding recommen-
dations and treatments: fosfomycin-trometamol was prescribed in
10,297 (69%) of cases, which is similar to several other studies car-
ried out in France [22,26,27]. Moreover, pivmecillinam was pre-
scribed in 1567 (10%) of teleconsultations, which is higher than
in previous studies, which presented rates neighboring 6% [21].
Nitrofurantoin is the recommended antibiotic therapy for cystitis
at risk of complication and was the fifth antibiotic of choice; it
was prescribed in 187 (2.7%) cases in association with urinary bac-
terial analysis. There was no significant difference in prescriptions
between the 2020 and 2021 study periods (p = 0.36).
Fluoroquinolones were the second most prescribed class of
molecules with 1568 (10.6%) prescriptions. This rate is lower than
in previous studies, which found prescription percentages for acute
cystitis ranging from 25 to 35% [22,23,27,28]. When comparing the
4
Infectious Diseases Now 53 (2023) 104707
data between July-August 2020 and July-August 2021, a decrease
was observed (p < 0.001), which could not be entirely explained
by the intervention. Poor access to information might contribute
to still significant overprescription of fluoroquinolones. That said,
decreased prescription of the latter was also observed in another
study [17] and might be reinforced by making sure that medical
software provide recommendations designed to avoid physician
non-compliance to guidelines for acute cystitis management in pri-
mary care [23,24,26].
After the intervention, prescription conformity in terms of nat-
ure of antibiotic was close to previous work on primary care [24].
However, on our work we observed less conformity for suspected
cystitis at risk of complication, and better conformity for the recur-
rent type.
Concerning limitations, a recruitment bias related to the young
age of patients comfortable with teleconsultation as a technical
tool was observed. If this study concerned suspected diagnosis, it
is because final diagnosis of acute cystitis cannot be retained as
an inclusion criterion insofar as in theory, it can only be given after
a urine dipstick/urine examination. Constraints on available tele-
consultation data related to automated extraction rendered us
unable to access all data necessary for assessment of cystitis man-
agement compliance in terms of antibiotic prescription (nature,
dose, duration). This was to some extent due to non-rigorous
physician use of prescription software.
It nonetheless bears mentioning that while software modifica-
tions leading to improved use of prescription software have been
brought about by the platform owner, this occurred subsequent
to our work. Furthermore, changes have been conducive to better
referencing of urine test strip variables, thereby optimizing pre-
scription via the software, whereas previously its prescription
was given by text.
Pre/post intervention analysis may entail interpretation bias; in
fact, we were unable to carry out additional explorations to deter-
mine whether the training or the contents offered were actually
being followed; as a result, it was not possible to accurately assess
dissemination of the educational intervention.
5. Conclusion
Acute cystitis is a frequent reason for seeking primary care. Its
treatment consists of prescribing a probabilistic antibiotic therapy
A. Jollivet, E. Caruana, J. Salomon et al.
or one that is secondarily adapted to the antibiogram helping to
avoid the emergence of bacterial resistance. The objective of this
study was to describe management, primarily among young
female patients, of suspected acute cystitis in the context of tele-
consultation. Prescriptions for first-line antibiotic therapy for
uncomplicated acute cystitis were mostly in line with the national
prescription recommendations for fosfomycin-trometamol. Pivme-
cillinam was also frequently prescribed, and fluoroquinolones were
still requested. Sensitizing doctors to the importance of appropri-
ate prescribing practices in acute cystitis is at times difficult, and
in many cases, their compliance remains insufficient. In point of
fact, teleconsultation has been shown to be associated with over-
prescription of urinary bacterial analysis in cystitis management.
These initial results open the way for the implementation of
good practice recommendations, specifically dedicated to the con-
straints of teleconsultation. Computerized technical capacities can
facilitate new learning dynamics, providing improved access to the
relevant recommendations.
Conflict of interest
The authors declare no conflict of interest.
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