Outpatient fluoroquinolone prescribing patterns before and after US FDA boxed warning

Association of outpatient fluoroquinolone prescribing with the National Medical Products Administration announcements of label changes in China

BACKGROUND

In 2017 and 2021, the National Medical Products Administration (NMPA) announced to revise the drug label of fluoroquinolones. We aimed to evaluate the association of fluoroquinolone prescribing with the NMPA announcements of label changes.

RESEARCH DESIGN AND METHODS

Monthly prevalence of fluoroquinolone prescriptions for uncomplicated urinary tract infections (uUTI), acute exacerbation of chronic bronchitis (AECB), and acute sinusitis (AS) between 2016 and 2022 was calculated, and interrupted time series analysis was applied to assess the impacts of NMPA label changes on fluoroquinolone use.

RESULTS

Prevalence of fluoroquinolone prescriptions decreased by 2.39% (95% CI, -4.72% to -0.07%) for uUTI but increased by 3.02% (95% CI, 1.71% to 4.34%) for AS immediately after the 2017 label change. Moreover, after the 2021 label change, fluoroquinolone use decreased shortly in all the three indications. However, a significant increasing trend was observed in fluoroquinolone use for AECB episodes, and fluoroquinolons were used for 61.4% of treated uUTI, 31.6% of treated AECB, and 5.42% of treated AS at the end of 2022, respectively.

CONCLUSIONS

The label changes issued by the NMPA had no substantial impacts on fluoroquinolone prescribing in the study region in China. Fluoroquinolone prescribing was still highly prevalent for uUTI and AECB and thus requiring further antimicrobial stewardship.

Antibiotic Stewardship Interventions for Urinary Tract Infections in Outpatient Settings: A Narrative Review

Inappropriate antibiotic choice or duration of therapy for urinary tract infections (UTIs) in outpatients is common and is a major contributor to antibiotic overuse. Most studies on outpatient antibiotic stewardship for UTIs follow a pre-design or post-design with a multifaceted intervention; these trials generally have found improvement in appropriateness of antibiotic use for UTI. Audit and feedback was one of the most commonly employed strategies across these trials but may not be sustainable. Future research on antibiotic stewardship for UTIs in outpatients should measure both effectiveness and implementation success.

The Diagnosis and Treatment of Adult Urinary Tract Infections in the Emergency Department

Emergency medicine has been called the art of "making complicated clinical decisions with limited information." This description is particularly relevant in the case of diagnosis and treatment of urinary tract infections (UTIs). Although common, UTIs are often challenging to diagnose given the presence of non-specific signs and symptoms and over-reliance on laboratory findings. This review provides an interdisciplinary interpretation of the primary literature and practice guidelines, with a focus on diagnostic and antimicrobial stewardship in the emergency department.

Evaluation of healthcare professionals' understanding of fluoroquinolones' safety profile, usage, and boxed warnings in Pakistan

INTRODUCTION

Fluoroquinolones (FQs) is a distinct class of antibiotics which are prescribed and used quite frequently worldwide, despite the box warnings (BW) issued by Food and Drug Administration (FDA). Literature has shown in spite of BWs related to FQs there is minimal impact on health care professionals (HCPs) prescribing habits, potentially attributing towards limited and insufficient awareness. In Pakistan, FQs are mostly prescribed antibiotics for microbial treatments, therefore the purpose of this study was to determine the level of knowledge about the safety profile, use, and BW of FQs among HCPs working in Pakistan.

METHODS

A cross-sectional study was undertaken among the HCPs of Khyber Pakhtunkhwa province of Pakistan from October 2022 to December 2022. A validated questionnaire was used to assess the knowledge of HCPs regarding FQs, its safety profile and BW. A random convenient sample technique was used while recruiting HCPs in this study. As the HCPs comprised physicians, dentists, pharmacist and nurses, all were approached in person and the study objective was fully elaborated and explained to them. The statistic test like: one-way ANOVA, independent-t test, multivariate logistic regression were used keeping the p-value < 0.05 as statistically significant.

RESULTS

A total of n = 250 HCPs were approached, of which n = 186 HCPs completed the questionnaire with a response rate of 74.4%. FQs prescribing pattern was only assessed among the prescribers, i.e., physicians and dentists (39/186). The mean knowledge score for indications was 5.29 ± 3.05, while for the adverse effects was 7.70 ± 2.61. The highest score for knowledge for indications and adverse effect score was achieved by physicians followed by dentist. The mean knowledge score for the BW was 3.46 ± 2.93 and among the HCPs for the BW of FQs, 20.4% of the HCPs had appropriate knowledge score (score ≥ 50%). The knowledge score was significantly higher in males (p = 0.039), dentists (p = 0.001), HCPs having master/specialization level of education (p = 0.003), HCPs working in government sector hospitals (p = 0.010) and secondary care hospitals (p = 0.001) while the multivariate logistic regression analysis showed that HCPs working in primary care hospital (OR: 6.2) and secondary care hospital (OR: 20.3) were associated with the tendency to achieve 50% or above knowledge score.

CONCLUSION

 Findings of this study reveals the unsatisfactory knowledge of HCPs regarding the safety profile, use, and BW of FQs putting patients at heightened risks of FQs associated AEs. Therefore, it is crucial to implement a national antimicrobial stewardship program, seminars and lectures aimed at continuously updating the knowledge of HCPs, regardless of their specialties, and effectively restrict the misuse of antimicrobial and disseminate FDA BWs in clinical practice.

Oral fluoroquinolones and risk of aortic aneurysm or dissection: A nationwide population-based propensity score-matched cohort study

STUDY OBJECTIVE

To investigate risk of aortic aneurysm or dissection in patients using oral fluoroquinolones compared to those using macrolides in real-world clinical practice among a large US general population.

DESIGN

Retrospective cohort study design.

DATA SOURCE

MarketScan commercial and Medicare supplemental databases.

PATIENTS

Adults patients with at least one prescription fill for fluoroquinolone or macrolide antibiotics.

INTERVENTION

Fluoroquinolone or macrolide antibiotics.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was estimated incidence of aortic aneurysm or dissection associated with the use of fluoroquinolones compared with macrolides during a 60-day follow-up period in a 1:1 propensity score-matched cohort. We identified 3,174,620 patients (1,587,310 in each group) after 1:1 propensity score matching. Crude incidence of aortic aneurysm or dissection was 1.9 cases per 1000 person-years among fluoroquinolone users and 1.2 cases per 1000 person-years among macrolide users. In multivariable Cox regression, compared with macrolides, the use of fluoroquinolones was associated with an increased risk of aortic aneurysm or dissection (aHR: 1.34; 95% CI: 1.17-1.54). The association was primarily driven by a high incidence of aortic aneurysm cases (95.8%). Results of sensitivity (e.g., fluoroquinolone exposure ranging from 7 to 14 days (aHR: 1.47; 95% CI: 1.26-1.71)) and subgroup analyses (e.g., ciprofloxacin (aHR: 1.26; 95% CI: 1.07-1.49) and levofloxacin (aHR: 1.44; 95% CI: 1.19-1.52)) remained consistent with main findings.

CONCLUSIONS

Fluoroquinolone use was associated with a 34% increased risk of aortic aneurysm or dissection compared with macrolide use among a general US population.

Impact of European Union Label Changes for Fluoroquinolone-Containing Medicinal Products for Systemic and Inhalation Use: Post-Referral Prescribing Trends

INTRODUCTION

Concerns of the persistence and severity of the adverse effects of fluoroquinolones, mainly involving the nervous system, muscles and joints, resulted in the 2018 referral procedure led by the European Medicines Agency (EMA). They advised to stop prescribing fluoroquinolones for infections of mild severity or of a presumed self-limiting course and for prevention of infections, plus to restrict prescriptions in cases of milder infections where other treatment options are available, and restrict in at-risk populations. We aimed to examine whether the impact of EMA regulatory interventions implemented throughout 2018-2019 had an impact on fluoroquinolone prescribing rates.

METHODS

A retrospective population-based cohort study was conducted using electronic health care records from six European countries between 2016 and 2021. We analysed monthly incident fluoroquinolone use rates overall and for each fluoroquinolone active substance through flexible modelling via segmented regression to detect time points of trend changes, in monthly percentage change (MPC).

RESULTS

The incidence of fluoroquinolone use ranged from 0.7 to 8.0/1000 persons per month over all calendar years. While changes in fluoroquinolone prescriptions were observed over time across countries, these were inconsistent and did not seem to be temporally related to EMA interventions (e.g., Belgium: February/May 2018, MPC - 33.3%, 95% confidence interval [CI] - 35.9 to - 30.7; Germany: February/May 2019, MPC - 12.6%, 95% CI - 13.7 to - 11.6]; UK: January/April 2016, MPC - 4.9%, 95% CI - 6.2 to - 3.6).

CONCLUSION

The regulatory action associated with the 2018 referral did not seem to have relevant effects on fluoroquinolone prescribing in primary care.

Developments in Non-Intercalating Bacterial Topoisomerase Inhibitors: Allosteric and ATPase Inhibitors of DNA Gyrase and Topoisomerase IV

Increases in antibiotic usage and antimicrobial resistance occurrence have caused a dramatic reduction in the effectiveness of many frontline antimicrobial treatments. Topoisomerase inhibitors including fluoroquinolones are broad-spectrum antibiotics used to treat a range of infections, which stabilise a topoisomerase-DNA cleavage complex via intercalation of the bound DNA. However, these are subject to bacterial resistance, predominantly in the form of single-nucleotide polymorphisms in the active site. Significant research has been undertaken searching for novel bioactive molecules capable of inhibiting bacterial topoisomerases at sites distal to the fluoroquinolone binding site. Notably, researchers have undertaken searches for anti-infective agents that can inhibit topoisomerases through alternate mechanisms. This review summarises work looking at the inhibition of topoisomerases predominantly through non-intercalating agents, including those acting at a novel allosteric site, ATPase domain inhibitors, and those offering unique binding modes and mechanisms of action.

Increase in the Rate of Gut Carriage of Fluoroquinolone-Resistant Escherichia coli despite a Reduction in Antibiotic Prescriptions

Background : Fluoroquinolone use for urinary tract infections has been steadily declining. Gut microbiota is the main reservoir for uropathogenic Escherichia coli but whether the carriage of fluoroquinolone-resistant E. coli has been changing is unknown. Methods . We determined the frequency of isolation and other characteristics of E. coli nonsuceptible to fluoroquinolones (at ³0.5 mg/L of ciprofloxacin) in 515 and 1605 E. coli -positive fecal samples collected in 2015 and 2021, respectively, from non-antibiotic- taking women of age 50+ receiving care in the Seattle area Kaiser Permanente Washington healthcare system. Results . Between 2015 and 2021 the prescription of fluoroquinolones dropped nearly three-fold in the study population. During the same period, the rates of gut carriage of fluoroquinolone-resistant E. coli increased from 14.4 % to 19.9% (P=.005), driven by a significant increase of isolates from the recently emerged, pandemic multi-drug resistant clonal group ST1193 (1.7% to 4.3%; P=.007) and those with an incomplete set of or no fluoroquinolone-resistance determining mutations (2.3% to 7.5%; P<.001). While prevalence of the resistance-associated mobile genes among the isolates dropped from 64.1% to 32.6% (P<.001), co-resistance to third generation cephalosporins has increased 21.5% to 33.1%, P=.044). Conclusion . Despite reduction in fluoroquinolone prescriptions, gut carriage of fluoroquinolone-resistant uropathogenic E. coli increased with a rise of previously sporadic lineages and co-resistance to third generation cephalosporins. Thus, to reduce the rates of antibiotic resistant urinary tract infections, greater focus should be on controlling the gut carriage of resistant bacteria.

Biotransformation of the Fluoroquinolone, Levofloxacin, by the White-Rot Fungus Coriolopsis gallica

The wastewater from hospitals, pharmaceutical industries and more generally human and animal dejections leads to environmental releases of antibiotics that cause severe problems for all living organisms. The aim of this study was to investigate the capacity of three fungal strains to biotransform the fluoroquinolone levofloxacin. The degradation processes were analyzed in solid and liquid media. Among the three fungal strains tested, Coriolopsis gallica strain CLBE55 (BRFM 3473) showed the highest removal efficiency, with a 15% decrease in antibiogram zone of inhibition for Escherichia coli cultured in solid medium and 25% degradation of the antibiotic in liquid medium based on high-performance liquid chromatography (HPLC). Proteomic analysis suggested that laccases and dye-decolorizing peroxidases such as extracellular enzymes could be involved in levofloxacin degradation, with a putative major role for laccases. Degradation products were proposed based on mass spectrometry analysis, and annotation suggested that the main product of biotransformation of levofloxacin by Coriolopsis gallica is an N-oxidized derivative.

Susceptibility to first choice antimicrobial treatment for urinary tract infections to Escherichia coli isolates from women urine samples in community South Brazil

E. coli is the main pathogen of UTI. It is important to be aware the local epidemiological data for an appropriate initial treatment. Resistance to antimicrobial agents has increased, especially to first-choice antibiotics in the treatment of cystitis. There are few studies on the sensivity profile of community uropathogen in our region.

OBJECTIVE

To characterize antimicrobials the sensitivity profile to E. coli isolated from urocultures of women treated at Basic Health Units and Emergency Care Units of Londrina- Paraná- Brazil during a period of 12 months (June 1, 2016 to June 1, 2017).

METHODOLOGY

A cross-sectional study was carried out from June 2016 to June 2017. All urine samples collected in the Basic Health Units and Emergency Departments in the city of Londrina (Paraná State, Brazil) were sent to a Central Laboratory where the identification and antimicrobial susceptibility testing were performed. Clinical Laboratory Standards Institute (CLSI) breakpoints were used for the interpretation of susceptibility testing results.

RESULTS

56,555 urine cultures were performed in the period, of which 8,832 were positive, of which 5,377 were women. Of these samples, 4.7% were enterobacteria producing extended-spectrum beta-lactamases (ESBL) and 15.5% resistant to quinolones. TMP- SMX was resistant in more than 30% of the samples in all age groups. Among quinolone-resistant isolates, resistance to cephalothin, ampicillin and sulfamethoxazole-trimethoprim was greater than 60%. Nitrofurantoin was the only antimicrobial that showed 90% of sensitivity.

CONCLUSION

The antimicrobials sensitivity profile was similar to that reported in the literature, with TMP- SMX resistance greater than 30% in the studied samples. Nitrofurantoin maintains high sensitivity rates greater than 90%. Resistance to quinolones increases proportionally with age, as well ESBL.

Assessment of Knowledge Regarding Safety Profile, Use, and Boxed Warnings of Fluoroquinolones Among Healthcare Professionals in Saudi Arabia: A Potential Implication for Drug Regulatory Authorities

Background

Despite a series of "boxed warnings" (BWs) issued by the US Food and Drug Administration (FDA), fluoroquinolones (FQs) are among the most prescribed antibiotics across the world. Moreover, few studies demonstrated that BW of FQs had less or no impact on prescribing patterns among healthcare professionals (HCPs), which might be attributed to the lack of knowledge toward such warnings. Since FQs contribute to a major proportion of antimicrobial prescriptions in the Kingdom of Saudi Arabia (KSA), this study aimed to ascertain the extent of knowledge toward safety profile, use, and BW of FQs among HCPs working in the KSA.

Methods

This cross-sectional study (May-August 2021) was conducted among HCPs working in KSA through a validated questionnaire. The HCPs were requested to identify the indications, adverse effects (AEs), and BW of FQs. The knowledge score (out of 40) was estimated among participants, and its association with demographics was ascertained through the chi-square test, Student's t-test, or Mann-Whitney U-test and one-way ANOVA, or Kruskal-Wallis test, where appropriate.

Results

Of the 573 participants (age: 36.1 ± 10.6 years, men: 59.7%), 262 (45.8%) were prescribers reporting frequent use of ciprofloxacin, levofloxacin, and ofloxacin. One-fourth (25.6%) of the prescribers did not recognize nalidixic acid as an agent from FQs class. About 60% of participants correctly identified the mechanism of action of FQs. The average knowledge score was 14.8 ± 6.4, where only 21.5% of respondents scored ≥50%. The average knowledge score for indications, AEs, and BW domains was 5.29 ± 3.05, 6.17 ± 4.05, and 2.3 ± 1.5, respectively. Only 75 (13.1%) participants recognized half of the BW, and 38.6% of participants identified at least one warning. The HCPs aged >40 years (p = 0.043), having non-Saudi's nationality (p < 0.001), working in Riyadh and Eastern regions (p < 0.001), having pharmacy and medicine disciplines (p < 0.001), practicing in public sectors (p = 0.004), and having more than 10 years of experience (p < 0.001) were significantly associated with high knowledge score.

Conclusion

This study demonstrates the unsatisfactory knowledge toward safety profile, use, and BW of FQs among HCPs which may put patients at increased risks of AEs. The knowledge score differed among various socio-demographic groups. There is a dire need to initiate the antimicrobial-focused educational campaigns among HCPs regardless of their specialties and methods to improve education and disseminate FDA warnings in practice.

Analysis of recurrent urinary tract infection management in women seen in outpatient settings reveals opportunities for antibiotic stewardship interventions

Objectives:

We characterized antibiotic prescribing patterns and management practices among recurrent urinary tract infection (rUTI) patients, and we identified factors associated with lack of guideline adherence to antibiotic choice, duration of treatment, and urine cultures obtained. We hypothesized that prior resistance to nitrofurantoin or trimethoprim–sulfamethoxazole (TMP-SMX), shorter intervals between rUTIs, and more frequent rUTIs would be associated with fluoroquinolone or β-lactam prescribing, or longer duration of therapy.

Methods:

This study was a retrospective database study of adult women with International Classification of Diseases, Tenth Revision (ICD-10) cystitis codes meeting American Urological Association rUTI criteria at outpatient clinics within our academic medical center between 2016 and 2018. We excluded patients with ICD-10 codes indicative of complicated UTI or pyelonephritis. Generalized estimating equations were used for risk-factor analysis.

Results:

Among 214 patients with 566 visits, 61.5% of prescriptions comprised first-line agents of nitrofurantoin (39.7%) and TMP-SMX (21.5%), followed by second-line choices of fluoroquinolones (27.2%) and β-lactams (11%). Most fluoroquinolone prescriptions (86.7%), TMP-SMX prescriptions (72.2%), and nitrofurantoin prescriptions (60.2%) exceeded the guideline-recommended duration. Approximately half of visits lacked a urine culture. Receiving care through urology via telephone was associated with receiving a β-lactam (adjusted odds ratio [aOR], 6.34; 95% confidence interval [CI], 2.58–15.56) or fluoroquinolone (OR, 2.28; 95% CI, 1.07–4.86). Having >2 rUTIs during the study period and seeking care from a urology practice (RR, 1.28, 95% CI, 1.15–1.44) were associated with longer antibiotic duration.

Conclusions:

We found low guideline concordance for antibiotic choice, duration of therapy and cultures obtained among rUTI patients. These factors represent new targets for outpatient antibiotic stewardship interventions.

Antibiotic resistance of Escherichia coli urinary tract infections at a North Carolina community hospital: Comparison of rural and urban community type

OBJECTIVE

We aimed to identify differences in urinary E. coli resistance rates based on community type of patient residence (rural and urban).

METHODS

This cross-sectional study examined antibiotic resistance of E. coli isolates from 12,604 urine specimens at a North Carolina hospital between 2016 and 2018. Using multivariable logistic regression modeling, we investigated the association between resistance and community type, adjusting for patient age, gender, season, and setting of infection onset. Analyses were performed using SAS Version 9.3 (SAS Institute, Cary, NC) at alpha = 0.05.

RESULTS

Prevalence of resistance was highest for ampicillin (42.2%), ampicillin-sulbactam (24.7%), ciprofloxacin (21.8%), trimethoprim-sulfamethoxazole (SXT) (21.6%), and levofloxacin (21.4%). Rural compared to urban community type was significantly associated with resistance of E. coli urinary isolates to ciprofloxacin (adjusted odds ratio [aOR] = 1.29, 95% confidence interval [CI] = 1.16-1.43, P < .0001), levofloxacin (aOR = 1.28, 95% CI = 1.15-1.42, P < .0001), SXT (aOR = 1.15, 95% CI = 1.04-1.27, P = .01), and nitrofurantoin (aOR = 1.57, 95% CI = 1.13-2.17, P = .01).

CONCLUSIONS

Rural community type may influence urinary E. coli resistance to fluoroquinolones, SXT, and nitrofurantoin, indicating the need for antimicrobial stewardship interventions in medically underserved populations.

The Five Ds of Outpatient Antibiotic Stewardship for Urinary Tract Infections

Urinary tract infections (UTI) are one of the most common indications for antibiotic prescriptions in the outpatient setting. Given rising rates of antibiotic resistance among uropathogens, antibiotic stewardship is critically needed to improve outpatient antibiotic use, including in outpatient clinics (primary care and specialty clinics) and emergency departments. Outpatient clinics are in general a neglected practice area in antibiotic stewardship programs, yet most antibiotic use in the United States is in the outpatient setting. This article provides a comprehensive review of antibiotic stewardship strategies for outpatient UTI in the adult population, with a focus on the "five Ds" of stewardship for UTI, including right diagnosis, right drug, right dose, right duration, and de-escalation. Stewardship interventions that have shown success for improving prescribing for outpatient UTI are discussed, including diagnostic stewardship strategies, such as reflex urine cultures, computerized decision support systems, and modified reporting of urine culture results. Among the many challenges to achieving stewardship for UTI in the outpatient setting, some of the most important are diagnostic uncertainty, increasing antibiotic resistance, limitations of guidelines, and time constraints of stewardship personnel and front-line providers. This article presents a stewardship framework, built on current evidence and expert opinion, that clinicians can use to guide their own outpatient management of UTI.

A global perspective on improving patient care in uncomplicated urinary tract infection: Expert consensus and practical guidance

BACKGROUND

Uncomplicated urinary tract infections (uUTIs) are a common problem in women. Management is mainly based on empirical prescribing, but there are concerns about overtreatment and antimicrobial resistance (AMR), especially in patients with recurrent uUTIs.

METHODS

A multidisciplinary panel of experts met to discuss diagnosis, treatment, prevention, guidelines, AMR, clinical trial design, and the impact of COVID-19 on clinical practice.

RESULTS

Symptoms remain the cornerstone of uUTI diagnosis, and urine culture is necessary only when empirical treatment fails, or rapid recurrence of symptoms or AMR is suspected. Specific antimicrobials are first-line therapy (typically nitrofurantoin, fosfomycin, trimethoprim-sulfamethoxazole, and pivmecillinam; dependent on availability and local resistance data). Fluoroquinolones are not first-line options for uUTIs due primarily to safety concerns, but also rising resistance rates. High-quality data to support most non-antimicrobial approaches are lacking. Local AMR data specific to community-acquired uUTIs are needed, but representative information is difficult to obtain; instead, identification of risk factors for AMR can provide a basis to guide empirical antimicrobial prescribing. The COVID-19 pandemic has impacted management of uUTIs in some countries and may have long-lasting implications for future models of care.

CONCLUSIONS

The management of uUTIs in women can be improved without increasing complexity, including simplified diagnosis, and empirical antimicrobial prescribing based on patient characteristics, including review of recent antimicrobial use and past pathogen resistance profiles, drug availability, and guidelines. Current data for non-antimicrobial approaches are limited. The influence of COVID-19 on telehealth could provide an opportunity to enhance patient care in the long term.

Association of Fluoroquinolone Prescribing Rates With Black Box Warnings from the US Food and Drug Administration

IMPORTANCE

In 2013 and 2016, the US Food and Drug Administration (FDA) issued warnings and recommended limited use of fluoroquinolones for patients with certain acute conditions. It is not clear how prescribers have responded to these warnings.

OBJECTIVE

To analyze changes in prescribing of fluoroquinolones after the 2013 and 2016 FDA warnings and to examine the physician characteristics associated with these changes.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used Medicare administrative claims data on Medicare fee-for-service beneficiaries and OneKey data on physicians and their organizations from January 1, 2011, to December 31, 2017. The sample was restricted to outpatient visits for sinusitis, bronchitis, and uncomplicated urinary tract infections. An interrupted time series approach was used to analyze the changes in the prescription rate after each FDA warning. Data analysis was performed between January 1, 2011, and December 31, 2017.

INTERVENTIONS

Two FDA black box warnings released in August 2013 and July 2016.

MAIN OUTCOMES AND MEASURES

The main outcome was an indicator for fluoroquinolone prescriptions in 3 periods: before the 2013 warning (baseline period), after the 2013 warning but before the 2016 warning (postwarning period 1), and after the 2016 warning (postwarning period 2).

RESULTS

The sample comprised 1 238 397 unique patients with a total of 2 720 071 outpatient acute care visits. Of this sample, 848 360 were women (68.5%), and the mean (SD) age was 69.7 (12.6) years. The immediate prescribing levels of fluoroquinolones in postwarning period 1 increased by 3.42 percentage points (95% CI, 3.23-3.62; P < .001) and declined by -0.77 percentage points (95% CI, -1.00 to -0.54; P < .001) in postwarning period 2. The prescribing trend increased by 0.08 percentage points per month (95% CI, 0.08-0.10; P < .001) in postwarning period 1 and 0.06 percentage points per month (95% CI, 0.04-0.08; P < .001) in postwarning period 2. In postwarning period 1, the prescribing levels for physicians who were affiliated with hospitals with a top 10th percentile case mix index vs those without such affiliation decreased by -1.13 percentage points (95% CI, -1.92 to -0.34; P = .005), whereas the levels for primary care physicians declined by -1.34 percentage points (95% CI, -1.78 to -0.88; P < .001) compared with non-primary care physicians in postwarning period 2. Physicians at teaching hospitals were the only ones who showed a decline in prescribing trend in postwarning period 1.

CONCLUSIONS AND RELEVANCE

This cross-sectional study found an overall decline in prescribing of fluoroquinolones after the release of FDA warnings. Understanding the association of physician and organizational characteristics with fluoroquinolone prescribing behavior may ultimately help to identify mechanisms to improve de-adoption.

Case-based audit and feedback around a decision aid improved antibiotic choice and duration for uncomplicated cystitis in primary care clinics

OBJECTIVES

The objective of our study was to evaluate the impact of a multifaceted stewardship intervention on adherence to the evidence-based practice guidelines on treatment of uncomplicated cystitis in primary care. We hypothesised that our intervention would increase guideline adherence in terms of antibiotic choice and duration of treatment.

DESIGN

A preintervention and postintervention comparison with a contemporaneous control group was performed. During the first two study periods, we obtained baseline data and performed interviews exploring provider prescribing decisions for cystitis at both clinics. During the third period in the intervention clinic only, the intervention included a didactic lecture, a decision algorithm and audit and feedback. We used a difference-in-differences analysis to determine the effects of our intervention on the outcome and guideline adherence to antibiotic choice and duration.

SETTING

Two family medicine clinics (one intervention and one control) were included.

PARTICIPANTS

All female patients with uncomplicated cystitis attending the study clinics between 2016 and 2019.

RESULTS

Our sample included 932 visits representing 812 unique patients with uncomplicated cystitis. The proportion of guideline-adherent antibiotic regimens increased during the intervention period (from 33.2% (95% CI 26.9 to 39.9) to 66.9% (95% CI 58.4 to 74.6) in the intervention site and from 5.3% (95% CI 2.3 to 10.1) to 17.0% (95% CI 9.9 to 26.6) in the control site). The increase in guideline adherence was greater in the intervention site compared with the control site with a difference-in-differences of 22 percentage points, p=0.001.

CONCLUSION

A multifaceted intervention increased guideline adherence for antibiotic choice and duration in greater magnitude than similar trends at the control site. Future research is needed to facilitate scale-up and sustainability of case-based audit and feedback interventions in primary care.

Droplet-Based Single-Cell Measurements of 16S rRNA Enable Integrated Bacteria Identification and Pheno-Molecular Antimicrobial Susceptibility Testing from Clinical Samples in 30 min

Empiric broad-spectrum antimicrobial treatments of urinary tract infections (UTIs) have contributed to widespread antimicrobial resistance. Clinical adoption of evidence-based treatments necessitates rapid diagnostic methods for pathogen identification (ID) and antimicrobial susceptibility testing (AST) with minimal sample preparation. In response, a microfluidic droplet-based platform is developed for achieving both ID and AST from urine samples within 30 min. In this platform, fluorogenic hybridization probes are utilized to detect 16S rRNA from single bacterial cells encapsulated in picoliter droplets, enabling molecular identification of uropathogenic bacteria directly from urine in as little as 16 min. Moreover, in-droplet single-bacterial measurements of 16S rRNA provide a surrogate for AST, shortening the exposure time to 10 min for gentamicin and ciprofloxacin. A fully integrated device and screening workflow were developed to test urine specimens for one of seven unique diagnostic outcomes including the presence/absence of Gram-negative bacteria, molecular ID of the bacteriaas Escherichia coli, an Enterobacterales, or other organism, and assessment of bacterial susceptibility to ciprofloxacin. In a 50-specimen clinical comparison study, the platform demonstrates excellent performance compared to clinical standard methods (areas-under-curves, AUCs >0.95), within a small fraction of the turnaround time, highlighting its clinical utility.

Prescribing Patterns of Antibiotics for the Self-Treatment of Travelers' Diarrhea in Global TravEpiNet, 2009-2018

Background

International travelers are often prescribed antibiotics for self-treatment of travelers' diarrhea (TD), but the benefits and risks of antibiotics are debated. We assessed the prescribing patterns of empiric antibiotics for TD in international travelers evaluated at Global TravEpiNet (GTEN) sites (2009-2018).

Methods

We performed a prospective, multisite cross-sectional study regarding antibiotic prescriptions for the self-treatment of TD at 31 GTEN sites providing pretravel consultations to adult international travelers. We described traveler demographics, itineraries, and antibiotic(s) prescribed. We used multivariable logistic regressions to assess the association of year of consultation with antibiotic prescribing (yes/no) and class (fluoroquinolones vs azithromycin). We performed interrupted time-series analyses to examine differences in prescribing before and after the Food and Drug Administration (FDA) warning on fluoroquinolones (July 2016).

Results

Antibiotics were not prescribed in 23 096 (22.2%) of 103 843 eligible pretravel GTEN consultations; azithromycin and fluoroquinolones were most frequently prescribed. Antibiotic prescribing declined significantly each year between 2009 and 2018 (odds ratio [OR], 0.84; 95% CI, 0.79-0.89), as did fluoroquinolone prescribing, relative to azithromycin (OR, 0.77; 95% CI, 0.73-0.82). The rate of decline in fluoroquinolone prescribing was significantly greater after the FDA fluoroquinolone warning (15.3%/year) than before (1.1%/year; P < .001).

Conclusions

Empiric antibiotics for TD were prescribed in >75% of pretravel GTEN consultations, but antibiotic prescribing declined steadily between 2009 and 2018. Fluoroquinolones were less frequently prescribed than azithromycin, especially after the 2016 FDA fluoroquinolone warning. Emphasis on the risks of antibiotics may influence antibiotic prescribing by providers for empiric treatment of TD.