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Running Head: PICO Question
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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
Running Head: PICO Question
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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.
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(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
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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 trimethoprimsulfamethoxazole 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
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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 multidrugresistant gram-negative bacilli in addition to wide spectrum b lactamase-strains and vancomycinresistant 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 Trimethoprimsulfamethoxazole (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 indepth 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.
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References:
Amabile-Cuevas, C.F. (2011) Antimicrobial activity data in support of nitrofurantoin three times
per day. Retrieved from
http://jac.oxfordjournals.org.libux.utmb.edu/content/66/7/1652.full.pdf+html
Cunha, B.A, Schoch P.E, & Hage, J.R (2011). Nitrofurantoin: Preferred Empiric Therapy for
Community-Acquired Lower Urinary Tract Infections. Retrieved from
http://pubmedcentralcanada.ca/pmcc/articles/PMC3228625/ .
Davis, C.P. (2012).Urinary tract infection. Retrieved from
http://www.medicinenet.com/urine_infection/article.htm
Fraser, T.N, Avellaneda, A.A, Graviss, E.A, & Musher, D.M.(2012). Acute kidney injury
associated with trimethoprim/sulfamethoxazole. Retrieved from
http://jac.oxfordjournals.org.libux.utmb.edu/content/67/5/1271.full.pdf+html
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
http://nyu.libguides.com/content.php?pid=27011&sid=551267
McKinnell, J.A, Stollenwerk, N.S, Jung, C.W, & Miller, L.G (2011) Nitrofurantoin compares
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favorably to recommended agents as empirical treatment of uncomplicated urinary tract
infections in decision and cost analysis. Retrieved from
http://web.ebscohost.com.libux.utmb.edu/ehost/pdfviewer/pdfviewer?vid=8&hid=
19&sid=512eac65-c3f4-4db9-b8d1-208bb15d9c50%40sessionmgr13.
Moyer, V. (2008) Weighing the Evidence: PICO Questions: what are they,
and why bother? Retrieved from
http://aapgrandrounds.aappublications.org/content/19/1/2.full