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Laytner LA, Trautner BW, Nash S, Faustinella F, Zoorob R, Olmeda K, Paasche-Orlow MK, Grigoryan L. Situations predisposing primary care patients to use antibiotics without a prescription in the United States. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e121. [PMID: 39257427 PMCID: PMC11384165 DOI: 10.1017/ash.2024.361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 05/15/2024] [Accepted: 05/17/2024] [Indexed: 09/12/2024]
Abstract
Background Patients' situations can impact their intentions to use antibiotics without medical guidance (non-prescription use) in the future. This survey determines the prevalence of intended (future) use of non-prescription antibiotics for 13 predefined situations and identifies the sociodemographic characteristics associated with intended use for these types of situations. Methods Patient surveys (N = 564) were conducted from January 2020 to June 2021 in the waiting rooms of 6 safety-net primary care clinics and 2 emergency departments in a private healthcare system. We used principal component analysis to identify 3 situational summary factors: barriers to a doctor visit, accessibility of non-prescription antibiotics, and previous symptom relief with antibiotics. Multivariate linear regression identified the sociodemographic predictors associated with each summary factor. Results The most common situations triggering patients to use non-prescription antibiotics were a perceived high cost of doctor visits (29.8%), having leftover prescription antibiotics (50.4%), and experiencing symptom relief with prior use of antibiotics (47.5%). Multivariate regression results revealed that younger patients (P < 0.04) and patients attending the safety-net health system (P < 0.001) had more intended use of non-prescription antibiotics for all 3 summary factors. Conclusions Future stewardship interventions should consider the types of situations that drive patients' decisions to use antibiotics without a prescription. Interventions aimed at reducing barriers to health care (eg, high costs and long waits associated with doctor appointments) and educating individuals on medically appropriate, nonantibiotic treatment options may reduce antibiotic use and antimicrobial resistance.
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Affiliation(s)
- Lindsey A Laytner
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Barbara W Trautner
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX, USA
| | - Susan Nash
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Fabrizia Faustinella
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Roger Zoorob
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Kiara Olmeda
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
| | | | - Larissa Grigoryan
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
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Mwape AK, Schmidtke KA, Brown C. Health care professionals' knowledge and attitudes towards antibiotic prescribing for the treatment of urinary tract infections: A systematic review. Br J Health Psychol 2024; 29:694-711. [PMID: 38494434 DOI: 10.1111/bjhp.12721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 02/07/2024] [Accepted: 03/06/2024] [Indexed: 03/19/2024]
Abstract
PURPOSE Previous models identify knowledge and attitudes that influence prescribing behaviour. The present study focuses on antibiotic prescribing for urinary tract infections (UTIs) to describe levels of health care professionals' knowledge and attitude factors in this area and how those levels are assessed. METHODS A systematic search was conducted to identify studies assessing the identified knowledge or attitude factors influencing health care professionals' antibiotic prescribing for urinary tract infections up to September 2022. Study quality was assessed using the Newcastle-Ottawa scale. Data were extracted about the types of factors assessed, the levels indicated and how those levels were assessed. Data were synthesized using counts, and levels were categorized as 'poor', 'moderate', 'high' or 'very high'. RESULTS Seven studies were identified, six of which relied entirely on closed-ended items. Levels of knowledge factors assessed were poor, for example, their 'knowledge of condition' and 'knowledge of task environment' were poor. Levels of the attitude factors assessed varied, for example, while health care professionals expressed moderate confidence in providing optimal patient care and appropriate attitude of fear towards the problem of antibiotic resistance, they expressed a poor attitude of complacency by giving into patient pressure to prescribe an antibiotic. CONCLUSIONS Present evidence suggests that clinicians have poor levels of knowledge and varying levels of attitudes about antibiotic prescribing for UTIs. However, few studies were identified, and assessments were largely limited to closed-ended types of questions. Future studies that assess more factors and employ open-ended question types could better inform future interventions to optimize antibiotic prescribing.
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Affiliation(s)
| | - Kelly Ann Schmidtke
- University of Health Science and Pharmacy in St Louis, St. Louis, Missouri, USA
| | - Celia Brown
- Warwick Medical School (WMS), University of Warwick, Coventry, UK
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Grigoryan L, Trautner BW. Antibiotic Stewardship Interventions for Urinary Tract Infections in Outpatient Settings: A Narrative Review. Infect Dis Clin North Am 2024; 38:277-294. [PMID: 38575491 DOI: 10.1016/j.idc.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
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.
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Affiliation(s)
- Larissa Grigoryan
- Department of Family and Community Medicine, Baylor College of Medicine, 3701 Kirby Drive, Suite 600, Houston TX 77098, USA; Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.
| | - Barbara W Trautner
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, IQuESt (152), 2002 Holcombe Boulevard, Houston, TX 77030, USA
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Sankar A, Everhart AO, Jena AB, Jeffery MM, Ross JS, Shah ND, Karaca-Mandic P. Longitudinal Patterns in Testosterone Prescribing After US FDA Safety Communication in 2014. Jt Comm J Qual Patient Saf 2023; 49:458-466. [PMID: 37380503 DOI: 10.1016/j.jcjq.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 05/18/2023] [Accepted: 05/19/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND The objective of this study was to describe changes in testosterone prescribing following a 2014 US Food and Drug Administration (FDA) safety communication and how changes varied by physician characteristics. METHODS Data were extracted from a 20% random sample of Medicare fee-for-service administrative claims data from 2011 through 2019. The sample included 1,544,604 unique male beneficiaries who received evaluation and management (E&M) services from 58,819 unique physicians that prescribed testosterone between 2011 and 2013. Patients were categorized based on presence of coronary artery disease (CAD) and non-age-related hypogonadism. Physician characteristics were identified in the OneKey database and included specialty and affiliations with teaching hospitals, for-profit hospitals, hospitals in integrated delivery networks, and hospitals in the top decile of case mix index. Linear segmented models described how testosterone prescriptions changed following a 2014 FDA safety communication and how changes were associated with physician and organizational characteristics. RESULTS Among 65,089,560 physician-patient-quarter-year observations, mean (standard deviation) age ranged from 72.16 (5.84) years for observations without CAD or non-age-related hypogonadism to 75.73 (6.92) years with CAD and without non-age-related hypogonadism. Following the safety communication, immediate changes in off-label testosterone prescription levels fell by 0.22 percentage points (pp) (95% confidence interval [CI] -0.33 to -0.11) for patients with CAD and by -0.16 pp (95% CI -0.19 to -0.16) for patients without CAD. A similar change was noticed in on-label prescribing levels. Off-label testosterone prescription quarterly trend, however, increased for patients with CAD and without CAD; on-label testosterone prescription trends declined for both groups. Declines in off-label prescribing were larger when treated by primary care physicians vs. non-primary care physicians, and physicians affiliated with teaching compared to nonteaching hospitals. Physician and organizational characteristics were not associated with changes in on-label prescribing. CONCLUSION On-label and off-label testosterone therapy declined following the FDA safety communication. Certain physician characteristics were associated with changes in off-label, but not on-label, prescribing.
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Tchesnokova V, Larson L, Basova I, Sledneva Y, Choudhury D, Solyanik T, Heng J, Bonilla TC, Pham S, Schartz EM, Madziwa LT, Holden E, Weissman SJ, Ralston JD, Sokurenko EV. Increase in the community circulation of ciprofloxacin-resistant Escherichia coli despite reduction in antibiotic prescriptions. COMMUNICATIONS MEDICINE 2023; 3:110. [PMID: 37567971 PMCID: PMC10421857 DOI: 10.1038/s43856-023-00337-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 07/20/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Community circulating gut microbiota is the main reservoir for uropathogenic Escherichia coli, including those resistant to antibiotics. Ciprofloxacin had been the primary antibiotic prescribed for urinary tract infections, but its broad use has been discouraged and steadily declined since 2015. How this change in prescriptions affected the community circulation of ciprofloxacin-resistant E. coli is unknown. METHODS We determined the frequency of isolation and other characteristics of E. coli resistant to ciprofloxacin in 515 and 1604 E. coli-positive fecal samples collected in 2015 and 2021, respectively. The samples were obtained from non-antibiotic-taking women of age 50+ receiving care in the Kaiser Permanente Washington healthcare system. RESULTS Here we show that despite a nearly three-fold drop in the prescription of ciprofloxacin between 2015 and 2021, the rates of gut carriage of ciprofloxacin-resistant E. coli increased from 14.2 % to 19.8% (P = .004). This is driven by a significant increase of isolates from the pandemic multi-drug resistant clonal group ST1193 (1.7% to 4.2%; P = .009) and isolates with relatively few ciprofloxacin-resistance determining chromosomal mutations (2.3% to 7.4%; P = .00003). Though prevalence of isolates with the plasmid-associated ciprofloxacin resistance dropped (59.0% to 30.9%; P = 2.7E-06), the isolates co-resistance to third generation cephalosporins has increased from 14.1% to 31.5% (P = .002). CONCLUSIONS Despite reduction in ciprofloxacin prescriptions, community circulation of the resistant uropathogenic E. coli increased with a rise of co-resistance to third generation cephalosporins. Thus, to reduce the rates of urinary tract infections refractory to antibiotic treatment, greater focus should be on controlling the resistant bacteria in gut microbiota.
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Affiliation(s)
- Veronika Tchesnokova
- Department of Microbiology, University of Washington School of Medicine, 1705 NE Pacific St., Seattle, WA, 98195, USA
| | - Lydia Larson
- Department of Microbiology, University of Washington School of Medicine, 1705 NE Pacific St., Seattle, WA, 98195, USA
| | - Irina Basova
- Department of Microbiology, University of Washington School of Medicine, 1705 NE Pacific St., Seattle, WA, 98195, USA
| | - Yulia Sledneva
- Department of Microbiology, University of Washington School of Medicine, 1705 NE Pacific St., Seattle, WA, 98195, USA
| | - Debarati Choudhury
- Department of Microbiology, University of Washington School of Medicine, 1705 NE Pacific St., Seattle, WA, 98195, USA
| | - Thalia Solyanik
- Department of Microbiology, University of Washington School of Medicine, 1705 NE Pacific St., Seattle, WA, 98195, USA
| | - Jennifer Heng
- Department of Microbiology, University of Washington School of Medicine, 1705 NE Pacific St., Seattle, WA, 98195, USA
| | - Teresa Christina Bonilla
- Department of Microbiology, University of Washington School of Medicine, 1705 NE Pacific St., Seattle, WA, 98195, USA
| | - Sophia Pham
- Department of Microbiology, University of Washington School of Medicine, 1705 NE Pacific St., Seattle, WA, 98195, USA
| | - Ellen M Schartz
- Kaiser Permanente Washington, 2715 Naches Ave. SW, Renton, WA, 98057, USA
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA, 98101-1466, USA
| | - Lawrence T Madziwa
- Kaiser Permanente Washington, 2715 Naches Ave. SW, Renton, WA, 98057, USA
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA, 98101-1466, USA
| | - Erika Holden
- Kaiser Permanente Washington, 2715 Naches Ave. SW, Renton, WA, 98057, USA
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA, 98101-1466, USA
| | - Scott J Weissman
- Department of Laboratory Medicine, Seattle Children's Hospital, 1100 Olive Way Tutor Center, Seattle, WA, 98101, USA
| | - James D Ralston
- Kaiser Permanente Washington, 2715 Naches Ave. SW, Renton, WA, 98057, USA
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA, 98101-1466, USA
| | - Evgeni V Sokurenko
- Department of Microbiology, University of Washington School of Medicine, 1705 NE Pacific St., Seattle, WA, 98195, USA.
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Kiggundu R, Waswa JP, Nakambale HN, Kakooza F, Kassuja H, Murungi M, Akello H, Morries S, Joshi MP, Stergachis A, Konduri N. Development and evaluation of a continuous quality improvement programme for antimicrobial stewardship in six hospitals in Uganda. BMJ Open Qual 2023; 12:e002293. [PMID: 37336576 DOI: 10.1136/bmjoq-2023-002293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 05/27/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND Appropriate antimicrobial use is essential for antimicrobial stewardship (AMS). Ugandan hospitals are making efforts to improve antibiotic use, but improvements have not been sufficiently documented and evaluated. METHODS Six Ugandan hospitals implemented AMS interventions between June 2019 and July 2022. We used the WHO AMS toolkit to set-up hospital AMS programmes and implemented interventions using continuous quality improvement (CQI) techniques and targeting conditions commonly associated with antibiotic misuse, that is, urinary tract infections (UTIs), upper respiratory tract infections (URTIs) and surgical antibiotic prophylaxis (SAP). The interventions included training, mentorship and provision of clinical guidelines to support clinical decision-making. Quarterly antibiotic use surveys were conducted. RESULTS Data were collected for 7037 patients diagnosed with UTIs. There was an increase in the proportion of patients receiving one antibiotic for the treatment of UTI from 48% during the pre-intervention to 73.2%, p<0.01. There was a 19.2% reduction in the number of antimicrobials per patient treated for UTI p<0.01. There was an increase in use of nitrofurantoin, the first-line drug for the management of UTI. There was an increase in the use of Access antibiotics for managing UTIs from 50.4% to 53.8%. The proportion of patients receiving no antimicrobials for URTI increased from 26.3% at pre-intervention compared with 53.4% at intervention phase, p<0.01. There was a 20.7% reduction in the mean number of antimicrobials per patient for URTI from the pre-intervention to the intervention phase, from 0.8 to 0.6, respectively, p<0.001 and reduction in the number of treatment days, p=0.0163. Among patients undergoing surgery, 49.5% (2212) received SAP during the pre-intervention versus 50.5% (2169) during the intervention. CONCLUSIONS Using CQI approaches to focus on specific causes of inappropriate antibiotic use led to desirable overall reductions in antibiotic use for URTI and UTI.
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Affiliation(s)
- Reuben Kiggundu
- USAID Medicines, Technologies, and Pharmaceutical Services (MTaPS) Program, Management Sciences for Health, Kampala, Uganda
| | - J P Waswa
- USAID Medicines, Technologies, and Pharmaceutical Services (MTaPS) Program, Management Sciences for Health, Kampala, Uganda
| | - Hilma N Nakambale
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Francis Kakooza
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Hassan Kassuja
- USAID Medicines, Technologies, and Pharmaceutical Services (MTaPS) Program, Management Sciences for Health, Kampala, Uganda
| | - Marion Murungi
- USAID Medicines, Technologies, and Pharmaceutical Services (MTaPS) Program, Management Sciences for Health, Kampala, Uganda
| | | | - Seru Morries
- Department of Pharmaceuticals and Natural Medicines, Ministry of Health, Kampala, Uganda
| | - Mohan P Joshi
- USAID Medicines, Technologies, and Pharmaceutical Services (MTaPS) Program, Management Sciences for Health, Arlington, Virginia, USA
| | - Andy Stergachis
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Pharmacy, University of Washington School of Pharmacy, Seattle, Washington, USA
| | - Niranjan Konduri
- USAID Medicines, Technologies, and Pharmaceutical Services (MTaPS) Program, Management Sciences for Health, Arlington, Virginia, USA
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Daumeyer NM, Kreitzberg D, Gavin KM, Bauer TA. Real-world evidence: Telemedicine for complicated cases of urinary tract infection. PLoS One 2023; 18:e0280386. [PMID: 36730176 PMCID: PMC9894494 DOI: 10.1371/journal.pone.0280386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 12/28/2022] [Indexed: 02/03/2023] Open
Abstract
Telemedicine programs for the treatment of urinary tract infections (UTIs) offer an opportunity to reduce burdens on patients and providers. However, these programs are typically restricted to patients with uncomplicated UTIs. This real-world analysis evaluated treatment and resolution rates in a large-scale, national UTI telemedicine program inclusive of patients with uncomplicated and complicated UTIs. We conducted a retrospective analysis of data obtained from a commercially available telemedicine program for the treatment of UTIs among adult women in the US between 2017 and 2021 (n = 51,474). The primary outcomes were the number of women who presented with symptoms of uncomplicated UTI, complicated UTI, and vaginal infection; prescription use and antibiotic type; symptom resolution within seven days after appointment; and treatment failure or relapse. Most patients reported frequent urination (94.4%), urgency (94.5%), and dysuria (97.6%). Those with uncomplicated UTI symptoms represented the majority of patients (61.6%); however, a substantial number of patients (36.5%) also reported at least one symptom associated with a complicated UTI. One-fifth of patients (19.2%) reported at least one co-occurring symptom of vaginal infection or sexually transmitted infection. Across all treated patients, 94.0% received recommended antibiotics according to the clinical protocol. Of the treated patients who provided follow-up data (n = 3,521), 89.7% reported seven-day symptom resolution. Symptom resolution rates were similar between patients with uncomplicated UTI symptoms (90.8%) and complicated UTI symptoms (87.9%), and symptom resolution among all treated patients (89.7%) was similar to reports for in-person standard of care. These findings suggest that large-scale telemedicine programs for the treatment of UTIs can be effective in the treatment of complicated UTIs.
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Affiliation(s)
| | | | - Kathleen M. Gavin
- Everly Health, Inc., Austin, Texas, United States of America
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Timothy A. Bauer
- Everly Health, Inc., Austin, Texas, United States of America
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
- * E-mail:
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Tchesnokova V, Larson L, Basova I, Sledneva Y, Choudhury D, Heng J, Solyanik T, Bonilla T, Pham S, Schartz E, Madziwa L, Holden E, Weissman S, Ralston J, Sokurenko E. Increase in the Rate of Gut Carriage of Fluoroquinolone-Resistant Escherichia coli despite a Reduction in Antibiotic Prescriptions. RESEARCH SQUARE 2023:rs.3.rs-2426668. [PMID: 36712036 PMCID: PMC9882669 DOI: 10.21203/rs.3.rs-2426668/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
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.
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Otake S, Kusama Y, Tsuzuki S, Myojin S, Kimura M, Kamiyoshi N, Takumi T, Ishida A, Kasai M. Comparing the effects of antimicrobial stewardship at primary emergency centers. Pediatr Int 2023; 65:e15614. [PMID: 37658628 DOI: 10.1111/ped.15614] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 06/24/2023] [Accepted: 06/30/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND Antimicrobial prescription rates tend to be high in outpatient settings and Primary Emergency Medical Centers (PECs) in Japan encounter difficulties in implementing antimicrobial stewardship programs (ASPs). While a nudge-based ASP publishing monthly newsletters reduces inappropriate prescription of oral third-generation cephalosporins (3GCs), which requires considerable effort. Therefore, developing more preferable ASP models in PECs is essential. METHODS We conducted a three-center, retrospective observational study. Himeji City Emergency Medical Center (Site A) introduced a facility-specific guideline for antimicrobial stewardship with reference to national guidelines. The Kobe Children's Primary Emergency Medical Center (Site B) provided the results of monitoring antibiotics prescription in a monthly newsletter. The Hanshin-Kita Children's First-Aid Center (Site C) did not perform a specific ASP. Prescription rates for 3GCs were categorized into pre- and post-intervention and compared using Poisson regression analysis. The difference-in-difference method was used to assess the effect of these interventions. RESULTS The numbers of patients pre- and post- intervention were 177,126 and 91,251, respectively. The 3GCs prescription rate at Site A, Site B, and Site C decreased from 6.7%, 4.2%, and 6.1% in 2016 to 2.3%, 1.0%, and 2.0% in 2019, respectively. Site B had a greater reduction than Site A and Site C (relative risk [RR] 0.71 [95% confidence interval (CI): 0.62-0.82]; p < 0.001, RR 0.71, [95% CI: 0.62-0.81]; p < 0.001). There was no significant difference between Site A and Site C (RR 1.00 [95% CI 0.88-1.13]; p = 0.963). CONCLUSION A facility-specific guideline was less effective than a nudge-based ASP for decreasing oral 3GC prescriptions in PECs.
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Affiliation(s)
- Shogo Otake
- Division of Infectious Disease, Department of Pediatrics, Kobe Children's Hospital, Kobe, Hyogo, Japan
| | - Yoshiki Kusama
- Department of Pediatrics, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo, Japan
- AMR Clinical Reference Center, Disease Control and Prevention Center, National Center for Global Health and Medicine Hospital, Tokyo, Japan
| | - Shinya Tsuzuki
- AMR Clinical Reference Center, Disease Control and Prevention Center, National Center for Global Health and Medicine Hospital, Tokyo, Japan
| | - Shota Myojin
- Division of Infectious Diseases, National Center for Child Health and Development, Tokyo, Japan
| | - Makoto Kimura
- Department of Pharmacy, Kobe Children's Primary Emergency Medical Center, Kobe, Hyogo, Japan
| | - Naohiro Kamiyoshi
- Department of Pediatrics, Red Cross Society Himeji Hospital, Himeji, Hyogo, Japan
| | - Toru Takumi
- Hanshin-Kita Children's First-Aid Center, Itami, Hyogo, Japan
| | - Akihito Ishida
- Kobe Children's Primary Emergency Medical Center, Kobe, Hyogo, Japan
| | - Masashi Kasai
- Division of Infectious Disease, Department of Pediatrics, Kobe Children's Hospital, Kobe, Hyogo, Japan
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Owusu H, Thekkur P, Ashubwe-Jalemba J, Hedidor GK, Corquaye O, Aggor A, Steele-Dadzie A, Ankrah D. Compliance to Guidelines in Prescribing Empirical Antibiotics for Individuals with Uncomplicated Urinary Tract Infection in a Primary Health Facility of Ghana, 2019-2021. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:12413. [PMID: 36231716 PMCID: PMC9566282 DOI: 10.3390/ijerph191912413] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 08/26/2022] [Accepted: 08/27/2022] [Indexed: 06/16/2023]
Abstract
Increasing trends in antimicrobial resistance among uropathogens call for rational use of empirical antibiotics for managing uncomplicated urinary tract infections (UTIs). In Ghana, standard treatment guidelines (STGs) for UTI recommend oral ciprofloxacin or cefuroxime for 5-7 days in females and 10-14 days in males. We conducted a cross-sectional audit using electronic medical records (EMR) to assess compliance to the STGs among adults (≥18 years) with uncomplicated UTIs diagnosed in a primary health facility between October 2019 and October 2021. Among 3717 patients, 71% were females and all had complete prescription details in the EMR. Of all the patients, 83% were prescribed empirical antibiotics, of whom 88% received oral ciprofloxacin or cefuroxime. Only 68% were prescribed antibiotics for the correct duration, which was significantly lower among males (10%) compared to females (90%). Among patients who received antibiotics, 60% were prescribed in line with the STGs. The results call for feedback to physicians about poor compliance to STGs with duration of antibiotic prescribed. Recommendations on 10-14 days duration of antibiotics for males needs to be reassessed and necessary amendments to STGs can be made. Leveraging the well-established EMR system, a real-time audit-feedback mechanism can be instituted to improve compliance with STGs.
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Affiliation(s)
- Helena Owusu
- Pharmacy Department, Korle Bu Teaching Hospital, Accra P.O. Box KB77, Ghana
| | - Pruthu Thekkur
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), 75001 Paris, France
- The Union South-East Asia Office (The USEA), New Delhi 110016, India
| | | | - George Kwesi Hedidor
- World Health Organization Country Office, Roman Ridge, Accra P.O. Box MB142, Ghana
| | - Oksana Corquaye
- Pharmacy Department, Korle Bu Teaching Hospital, Accra P.O. Box KB77, Ghana
| | - Asiwome Aggor
- Pharmacy Department, Korle Bu Teaching Hospital, Accra P.O. Box KB77, Ghana
| | - Allen Steele-Dadzie
- Polyclinic/Family Medicine Department, Korle Bu Teaching Hospital, Accra P.O. Box KB77, Ghana
| | - Daniel Ankrah
- Pharmacy Department, Korle Bu Teaching Hospital, Accra P.O. Box KB77, Ghana
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Piraux A, Hammoud R, Riou J, Lebdai S, Faure S. Assessment of the Compliance of Cystitis Management According to French Recommendations through the Analysis of Prescriptions Collected in Community Pharmacies. Antibiotics (Basel) 2022; 11:antibiotics11070976. [PMID: 35884230 PMCID: PMC9312117 DOI: 10.3390/antibiotics11070976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 07/13/2022] [Accepted: 07/18/2022] [Indexed: 02/01/2023] Open
Abstract
Urinary tract infections, especially cystitis, are common infections; they are the second most prevalent cause of antibiotic prescriptions in community pharmacies. To reduce antimicrobial resistance, guidelines are revised regularly. This study aims to assess compliance between prescriptions collected in community pharmacies and French cystitis guidelines. A treatment is considered compliant if the nature, dosage, and duration of the antibiotics are correct. Only women aged 18–65 years with a diagnosis of cystitis were eligible. The participation of 16 pharmacies resulted in 303 prescriptions. Most infections were classified as uncomplicated cystitis (79.2%), general practitioners were the prescribers in more than 9 out of 10 cases, and fosfomycin trometamol was the antibiotic dispensed for 1 in 2 women. An average compliance of 66% was observed, but with disparities according to the type of cystitis. Two-thirds of cases of uncomplicated cystitis and recurrent cystitis followed the recommendations, whereas only 15% of cystitis cases that were at risk of complication did so. The inclusion of a urine examination in uncomplicated cystitis decreased the overall compliance rate to 5.8%. These results show the essential role played by pharmacists; they are the last line of defence before dispensing antibiotics. They must know the recommendations in order to apply them.
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Affiliation(s)
- Arthur Piraux
- University of Angers, Inserm, CNRS, MINT, SFR ICAT, F-49000 Angers, France;
- Correspondence:
| | - Ramy Hammoud
- Methodology and Biostatistics Department, University of Angers, F-49000 Angers, France;
| | - Jérémie Riou
- University of Angers, Inserm, CHU Angers, CNRS, MINT, SFR ICAT, F-49000 Angers, France;
| | - Souhil Lebdai
- Department of Urology, Angers University Hospital, F-49000 Angers, France;
| | - Sébastien Faure
- University of Angers, Inserm, CNRS, MINT, SFR ICAT, F-49000 Angers, France;
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12
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Funaro JR, Moehring RW, Liu B, Lee HJ, Yang S, Sarubbi CB, Anderson DJ, Wrenn RH. Impact of Education and Data Feedback on Guideline-Concordant Prescribing for Urinary Tract Infections in the Outpatient Setting. Open Forum Infect Dis 2022; 9:ofab214. [PMID: 35146036 PMCID: PMC8825625 DOI: 10.1093/ofid/ofab214] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 04/26/2021] [Indexed: 01/09/2023] Open
Abstract
Background Urinary tract infections (UTIs) are the most common outpatient indication for antibiotics and an important target for antimicrobial stewardship (AS) activities. With The Joint Commission standards now requiring outpatient AS, data supporting effective strategies are needed. Methods We conducted a 2-phase, prospective, quasi-experimental study to estimate the effect of an outpatient AS intervention on guideline-concordant antibiotic prescribing in a primary care (PC) clinic and an urgent care (UC) clinic between August 2017 and July 2019. Phase 1 of the intervention included the development of clinic-specific antibiograms and UTI diagnosis and treatment guidelines, presented during educational sessions with clinic providers. Phase 2, consisting of routine clinic- and provider-specific feedback, began ~12 months after the initial education. The primary outcome was percentage of encounters with first- or second-line antibiotics prescribed according to clinic-specific guidelines and was assessed using an interrupted time series approach. Results Data were collected on 4724 distinct patients seen during 6318 UTI encounters. The percentage of guideline-concordant prescribing increased by 22% (95% CI, 12% to 32%) after Phase 1 education, but decreased by 0.5% every 2 weeks afterwards (95% CI, –0.9% to 0%). Following routine data feedback in Phase 2, guideline concordance stabilized, and significant further decline was not seen (–0.6%; 95% CI, –1.6% to 0.4%). This shift in prescribing patterns resulted in a 52% decrease in fluoroquinolone use. Conclusions Clinicians increased guideline-concordant prescribing, reduced UTI diagnoses, and limited use of high-collateral damage agents following this outpatient AS intervention. Routine data feedback was effective to maintain the response to the initial education.
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Affiliation(s)
- Jason R Funaro
- Department of Pharmacy, Duke University Medical Center, Durham, North Carolina, USA
| | - Rebekah W Moehring
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Beiyu Liu
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA
| | - Hui-Jie Lee
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA
| | - Siyun Yang
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA
| | - Christina B Sarubbi
- Department of Pharmacy, Duke University Medical Center, Durham, North Carolina, USA.,Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Deverick J Anderson
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Rebekah H Wrenn
- Department of Pharmacy, Duke University Medical Center, Durham, North Carolina, USA.,Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
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Yoon C, Park SY, Kim B, Kwon KT, Ryu SY, Wie SH, Jo HU, Kim J, Hong KW, Kim HI, Kim HA, Kim MH, Bae MH, Sohn YH, Kim J, Lee Y, Pai H. Relationship between the appropriateness of antibiotic treatment and clinical outcomes/medical costs of patients with community-acquired acute pyelonephritis: a multicenter prospective cohort study. BMC Infect Dis 2022; 22:112. [PMID: 35105335 PMCID: PMC8805410 DOI: 10.1186/s12879-022-07097-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 01/27/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Inappropriate use of antibiotics not only increases antibiotic resistance as collateral damage but also increases clinical failure rates and medical costs. The purpose of this study was to determine the relationship between the appropriateness of antibiotic prescription and outcomes of community-acquired acute pyelonephritis (CA-APN). METHODS A multicenter prospective cohort study was conducted at eight hospitals in Korea between September 2017 and August 2018. All hospitalized patients aged ≥ 19 years who were diagnosed with CA-APN on admission were recruited. The appropriateness of empirical and definitive antibiotics, as well as the appropriateness of antibiotic treatment duration and route of administration, was evaluated in accordance with the guideline and expert opinions. Clinical outcomes and medical costs were compared between patients who were administered antibiotics 'appropriately' and 'inappropriately.' RESULTS A total of 397 and 318 patients were eligible for the analysis of the appropriateness of empirical and definitive antibiotics, respectively. Of them, 10 (2.5%) and 18 (5.7%) were administered 'inappropriately' empirical and definitive antibiotics, respectively. Of the 119 patients whose use of both empirical and definitive antibiotics was classified as 'optimal,' 57 (47.9%) received antibiotics over a longer duration than that recommended; 67 (56.3%) did not change to oral antibiotics on day 7 of hospitalization, even after stabilization of the clinical symptoms. Patients who were administered empirical antibiotics 'appropriately' had shorter hospitalization days (8 vs. 10 days, P = 0.001) and lower medical costs (2381.9 vs. 3235.9 USD, P = 0.002) than those who were administered them 'inappropriately.' Similar findings were observed for patients administered both empirical and definitive antibiotics 'appropriately' and those administered either empirical or definitive antibiotics 'inappropriately'. CONCLUSIONS Appropriate use of antibiotics leads to better outcomes, including reduced hospitalization duration and medical costs.
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Affiliation(s)
- Choseok Yoon
- The Medical Commend of Internal Medicine, 27th Infantry Division Medical Team, Republic of Korea Army, Hwacheon, Korea
| | - Se Yoon Park
- Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Bongyoung Kim
- Department of Internal Medicine, Hanyang University College of Medicine, 222-1, Wangsimni-ro, Seongdong-gu, Seoul, 04763, Korea.
| | - Ki Tae Kwon
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Seong-Yeol Ryu
- Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Seong-Heon Wie
- Division of Infectious Diseases, Department of Internal Medicine, St. Vincent Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyun-Uk Jo
- Department of Urology, Good Moonhwa Hospital, Busan, Korea
| | - Jieun Kim
- Department of Internal Medicine, Hanyang University College of Medicine, 222-1, Wangsimni-ro, Seongdong-gu, Seoul, 04763, Korea
| | - Kyung-Wook Hong
- Division of Infectious Diseases, Department of Internal Medicine, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Hye In Kim
- Department of Internal Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Hyun Ah Kim
- Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Mi-Hee Kim
- Division of Infectious Diseases, Department of Internal Medicine, St. Vincent Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Mi-Hyun Bae
- Department of Laboratory Medicine, College of Medicine, Hanyang University, Seoul, Korea
| | | | - Jieun Kim
- Department of Laboratory Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Yangsoon Lee
- Department of Laboratory Medicine, College of Medicine, Hanyang University, Seoul, Korea
| | - Hyunjoo Pai
- Department of Internal Medicine, Hanyang University College of Medicine, 222-1, Wangsimni-ro, Seongdong-gu, Seoul, 04763, Korea
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14
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Kon S, Meslovich D, Valdez C, Jenkins TC, Shihadeh K, Franco-Paredes C, Price CS. Long-term impact of fluoroquinolone-sparing strategies for empirical treatment of acute uncomplicated cystitis among ambulatory patients. Ther Adv Infect Dis 2022; 9:20499361221129415. [PMID: 36225854 PMCID: PMC9549079 DOI: 10.1177/20499361221129415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 09/13/2022] [Indexed: 11/06/2022] Open
Abstract
Background Acute uncomplicated cystitis is common among outpatients and frequently leads to antibiotic prescriptions, making urinary tract infections (UTIs) an important area for antimicrobial stewardship initiatives. Infectious Disease Society of America (IDSA) guidelines promote alternative agents in place of fluoroquinolones for acute uncomplicated cystitis. Despite IDSA guidance, adherence to the guideline remains low in the United States (US). Several studies have described interventions to improve guideline-concordant prescribing for UTIs. However, the long-term sustainability and impact of fluoroquinolone (FLQ)-sparing strategies on community antimicrobial resistance and treatment outcomes are unknown. The objectives of this study were to characterize current antibiotic prescribing patterns, treatment failures and Escherichia coli resistance rates in a setting which instituted FLQ sparing strategies for UTIs in 2007. Methods Retrospective cohort study of women aged ⩾ 18 diagnosed with acute uncomplicated cystitis based on International Classification of Diseases, 10th Revision (ICD-10) codes were included. Data were abstracted for ambulatory visits over a 6-month period, January 2018 to June 2018, at a large urban health care system. Treatment decisions were made by individual providers, and data were analyzed retrospectively. Nitrofurantoin (NFT) resistance was obtained from the institutional antibiogram and patient-level data. Treatment failure was defined as the need for a different antibiotic for UTI within 28 days of the original prescription. Results NFT was the most frequently prescribed antibiotic (n = 386, 71.6%) of empiric antibiotic prescriptions for UTIs. FLQs comprised 4.6% of all antibiotic prescriptions (n = 25). Treatment failure rate was 2.3% in patients treated with NFT. Urine culture was ordered for only 26.8% of patients. Among the small group of patients with cultures ordered, E. coli remained 98.5% susceptible to NFT. Conclusions This study is the first to report significantly low rates (4.6%) of FLQ prescribing for acute uncomplicated cystitis. Treatment failure rate was low with empiric NFT. Increased NFT resistance among E. coli was not observed at the institution or among the subset of patients with E. coli positive urine cultures. These findings support current IDSA treatment guidance for uncomplicated cystitis.
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Affiliation(s)
- Shelley Kon
- Medical Director of Infection Prevention and
Antibiotic Stewardship, Rocky Mountain Regional VA Medical Center, 1700 N.
Wheeling St. (111L), Aurora, CO 80045, USA
- Assistant Professor, University of Colorado
School of Medicine, Aurora, CO, USA
| | | | | | - Timothy C. Jenkins
- Denver Health, Denver, Colorado, USA
- University of Colorado School of Medicine,
Aurora, CO, USA
| | | | - Carlos Franco-Paredes
- University of Colorado School of Medicine,
Aurora, CO, USA
- University of Colorado Hospital, Aurora, CO,
USA
| | - Connie S. Price
- Chief Medical Officer, Denver Health and
Hospital Authority, 601 Broadway St., Denver, CO 80204, USA
- Professor of Medicine (Infectious Diseases),
University of Colorado School of Medicine, Aurora, CO, USA
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15
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Pilla SJ, Pitts SI, Maruthur NM. High Concurrent Use of Sulfonylureas and Antimicrobials With Drug Interactions Causing Hypoglycemia. J Patient Saf 2022; 18:e217-e224. [PMID: 32569099 DOI: 10.1097/pts.0000000000000739] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Sulfonylureas, the second most common oral diabetes treatment, have interactions with antimicrobials that substantially increase the risk of hypoglycemia. The objectives of this study are to quantify the concurrent use of sulfonylureas and interacting antimicrobial in U.S. ambulatory care and to examine whether interacting antimicrobials are used for an appropriate indication. METHODS We analyzed the 2006-2016 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, annual probability samples of visits to U.S. office-based physicians. We determined nationally representative estimates of visits for adults with concurrent use of sulfonylureas and 7 antimicrobials with established interactions. We examined whether visit diagnoses included appropriate indications for antibiotics according to national guidelines. RESULTS There were 2.5 million visits per year (95% confidence interval [CI] 2.2-2.9) in which sulfonylureas were used with systemic antimicrobials, of which 1 million (95% CI, 0.8-1.2) or 38.0% (95% CI, 32.3%-44.0%) were interacting antimicrobials. Sulfonylurea users had similar odds of interacting antimicrobial use as patients using diabetes medications without antimicrobial interactions (adjusted odds ratio, 1.07; 95% CI, 0.82-1.40). The most common interacting antimicrobials used with sulfonylureas were fluoroquinolones, accounting for 59.9% (95% CI, 50.7%-68.2%) of antimicrobials, and sulfamethoxazole-trimethoprim, accounting for 21.1% (95% CI, 14.8%-29.2%). There was no appropriate antibiotic indication in 69.7% (95% CI, 55.2%-81.1) of visits with interacting antibiotic use. CONCLUSIONS Sulfonylureas and antimicrobials with potentially hazardous interactions are frequently used together. To reduce resultant hypoglycemic events, there is a need for interventions to increase physician awareness and promote antibiotic stewardship.
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16
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Analysis of recurrent urinary tract infection management in women seen in outpatient settings reveals opportunities for antibiotic stewardship interventions. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2022; 2:e8. [PMID: 36310787 PMCID: PMC9614978 DOI: 10.1017/ash.2021.224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 10/11/2021] [Accepted: 10/13/2021] [Indexed: 12/03/2022]
Abstract
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.
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17
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Goebel MC, Trautner BW, Grigoryan L. The Five Ds of Outpatient Antibiotic Stewardship for Urinary Tract Infections. Clin Microbiol Rev 2021; 34:e0000320. [PMID: 34431702 PMCID: PMC8404614 DOI: 10.1128/cmr.00003-20] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
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.
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Affiliation(s)
- Melanie C. Goebel
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Barbara W. Trautner
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Larissa Grigoryan
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas, USA
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18
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Grigoryan L, Zoorob R, Germanos G, Sidani M, Horsfield M, Khan F, Zare M, Goebel M, Atmar R, Trautner B. Case-based audit and feedback around a decision aid improved antibiotic choice and duration for uncomplicated cystitis in primary care clinics. Fam Med Community Health 2021; 9:fmch-2020-000834. [PMID: 34244304 PMCID: PMC8273487 DOI: 10.1136/fmch-2020-000834] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Larissa Grigoryan
- Family and Community Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Roger Zoorob
- Family and Community Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - George Germanos
- Family and Community Medicine, Baylor College of Medicine, Houston, Texas, USA.,Internal Medicine, Desert Regional Medical Center, Palm Springs, California, USA
| | - Mohamad Sidani
- Family and Community Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Matthew Horsfield
- Family and Community Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Fareed Khan
- Family and Community Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Mohammad Zare
- Family and Community Medicine, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Melanie Goebel
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Robert Atmar
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Barbara Trautner
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Department of Medicine, Baylor College of Medicine, Michael E DeBakey VA Medical Center, Houston, Texas, USA
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19
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Kanjilal S, Oberst M, Boominathan S, Zhou H, Hooper DC, Sontag D. A decision algorithm to promote outpatient antimicrobial stewardship for uncomplicated urinary tract infection. Sci Transl Med 2021; 12:12/568/eaay5067. [PMID: 33148625 DOI: 10.1126/scitranslmed.aay5067] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 09/11/2019] [Accepted: 10/16/2020] [Indexed: 11/02/2022]
Abstract
Antibiotic resistance is a major cause of treatment failure and leads to increased use of broad-spectrum agents, which begets further resistance. This vicious cycle is epitomized by uncomplicated urinary tract infection (UTI), which affects one in two women during their life and is associated with increasing antibiotic resistance and high rates of prescription for broad-spectrum second-line agents. To address this, we developed machine learning models to predict antibiotic susceptibility using electronic health record data and built a decision algorithm for recommending the narrowest possible antibiotic to which a specimen is susceptible. When applied to a test cohort of 3629 patients presenting between 2014 and 2016, the algorithm achieved a 67% reduction in the use of second-line antibiotics relative to clinicians. At the same time, it reduced inappropriate antibiotic therapy, defined as the choice of a treatment to which a specimen is resistant, by 18% relative to clinicians. For specimens where clinicians chose a second-line drug but the algorithm chose a first-line drug, 92% (1066 of 1157) of decisions ended up being susceptible to the first-line drug. When clinicians chose an inappropriate first-line drug, the algorithm chose an appropriate first-line drug 47% (183 of 392) of the time. Our machine learning decision algorithm provides antibiotic stewardship for a common infectious syndrome by maximizing reductions in broad-spectrum antibiotic use while maintaining optimal treatment outcomes. Further work is necessary to improve generalizability by training models in more diverse populations.
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Affiliation(s)
- Sanjat Kanjilal
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, MA 02215, USA.,Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Michael Oberst
- Institute for Medical Engineering and Sciences, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Sooraj Boominathan
- Institute for Medical Engineering and Sciences, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Helen Zhou
- Machine Learning Department, Carnegie Mellon University, Pittsburgh, PA 15213, USA
| | - David C Hooper
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA 02114, USA
| | - David Sontag
- Institute for Medical Engineering and Sciences, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.
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Mullakary J, Visintainer S, Tucci M, Dionne B, Conley MP, Reid DJ, Matta TM, Bartucca MA, Bouwmeester CJ. A multicenter retrospective review of antibiotic prescribing patterns for treatment of urinary tract infections in the primary care setting. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021. [DOI: 10.1002/jac5.1430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Jenny Mullakary
- Department of Pharmacy and Health Systems Sciences Northeastern University Boston Massachusetts USA
- Harbor Health Services, Inc. Mattapan Massachusetts USA
- Clinical Pharmacy Department Atrius Health Watertown Massachusetts USA
| | - Sarah Visintainer
- Department of Pharmacy and Health Systems Sciences Northeastern University Boston Massachusetts USA
- Harbor Health Elder Service Plan Mattapan Massachusetts USA
- Clinical Pharmacy Department Shields Health Solutions Stoughton Massachusetts USA
| | - Mitchell Tucci
- Department of Pharmacy and Health Systems Sciences Northeastern University Boston Massachusetts USA
- The Dimock Center Roxbury Massachusetts USA
- Pharmacy Department CVS Pharmacy Boston Massachusetts USA
| | - Brandon Dionne
- Department of Pharmacy and Health Systems Sciences Northeastern University Boston Massachusetts USA
- Brigham and Women's Hospital Boston Massachusetts USA
| | - Michael P. Conley
- Department of Pharmacy and Health Systems Sciences Northeastern University Boston Massachusetts USA
- Harbor Health Services, Inc. Mattapan Massachusetts USA
| | - Debra J. Reid
- Department of Pharmacy and Health Systems Sciences Northeastern University Boston Massachusetts USA
- The Dimock Center Roxbury Massachusetts USA
| | - Thomas M. Matta
- Department of Pharmacy and Health Systems Sciences Northeastern University Boston Massachusetts USA
- Harbor Health Services, Inc. Mattapan Massachusetts USA
| | - Macayla A. Bartucca
- Department of Pharmacy and Health Systems Sciences Northeastern University Boston Massachusetts USA
- Harbor Health Elder Service Plan Mattapan Massachusetts USA
| | - Carla J. Bouwmeester
- Department of Pharmacy and Health Systems Sciences Northeastern University Boston Massachusetts USA
- Harbor Health Elder Service Plan Mattapan Massachusetts USA
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21
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Sefah IA, Essah DO, Kurdi A, Sneddon J, Alalbila TM, Kordorwu H, Godman B. Assessment of adherence to pneumonia guidelines and its determinants in an ambulatory care clinic in Ghana: findings and implications for the future. JAC Antimicrob Resist 2021; 3:dlab080. [PMID: 34223139 PMCID: PMC8210001 DOI: 10.1093/jacamr/dlab080] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 05/12/2021] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Adherence to local standard guidelines is seen as a pragmatic way to measure and improve the quality of future prescribing in ambulatory care to reduce morbidity, mortality and healthcare costs. OBJECTIVES To evaluate adherence to the Ghana Standard Treatment Guidelines (STGs) for the empirical antibiotic treatment of ambulatory care patients with community-acquired pneumonia (CAP) in a region in Ghana and factors associated with it. METHODS A cross-sectional survey was conducted using a checklist to collect data from the hospital electronic database, which included sociodemographic details, payment type and clinical information of all ambulatory patients attending Keta Municipal Hospital, diagnosed and managed for CAP from September 2018 to January 2019. Prescriptions were assessed for adherence to the Ghana STG based on choice of antibiotics. A χ2 test and multiple logistic regression were subsequently conducted. RESULTS A total of 1929 patient records with diagnosis of CAP within the study period at the ambulatory clinic were identified. The overall rate of adherence to the Ghana STG was 32.50% (n = 627). From the patient records collected, 62.50% were female, 41.84% were children (0-12 years), and 97.15% had a valid national health insurance status. Adherence was associated with the duration of antibiotic prescribing, number of additional antibiotics prescribed and some patients' clinical characteristics. CONCLUSIONS The rate of adherence to Ghana STG among the study population was low. Efforts must be made to train and encourage prescribers to follow empirical guidelines to reduce inappropriate selection of antibiotics in the ambulatory care settings.
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Affiliation(s)
- Israel Abebrese Sefah
- Pharmacy Practice Department of Pharmacy Practice, School of Pharmacy, University of Health and Allied Sciences, Volta Region, Ghana
- Pharmacy Department, Keta Municipal Hospital, Ghana Health Service, Keta-Dzelukope, Ghana
| | - Darius Obeng Essah
- Pharmacy Department, Keta Municipal Hospital, Ghana Health Service, Keta-Dzelukope, Ghana
| | - Amanj Kurdi
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, G4 0RE, UK
- Department of Pharmacology, College of Pharmacy, Hawler Medical University, Erbil, Iraq
| | - Jacqueline Sneddon
- Scottish Antimicrobial Prescribing Group, Healthcare Improvement Scotland, Delta House, 50 West Nile Street, Glasgow, G12NP, UK
| | - Thelma Mpoku Alalbila
- Pharmacy Department, Keta Municipal Hospital, Ghana Health Service, Keta-Dzelukope, Ghana
| | - Hope Kordorwu
- Nursing Department, Keta Municipal Hospital, Ghana Health Service, Keta-Dzelukope, Ghana
| | - Brian Godman
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, G4 0RE, UK
- School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, Pretoria, 0208, South Africa
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
- Division of Clinical Pharmacology, Karolinska Institute, Karolinska University Hospital Huddinge, Stockholm, Sweden
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22
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Adherence to guideline recommendations for urinary tract infections in adult women: a cross-sectional study. Prim Health Care Res Dev 2021; 22:e11. [PMID: 33818360 PMCID: PMC8101080 DOI: 10.1017/s1463423621000116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
AIM To study whether changes in drug preferences in the Dutch guideline for the treatment of Urinary Tract Infection (UTI) for General Practitioners (GPs) in 2013, resulted in corresponding changes in antibiotic dispensing. BACKGROUND For the treatment of uncomplicated UTI, nitrofurantoin remained the first choice, while fosfomycin became the second choice and changed ranks with trimethoprim. For a subsequent febrile UTI, ciprofloxacin became the first choice and changed ranks with amoxicillin/clavulanic acid, co-trimoxazole remained the third choice. METHODS In this observational cross-sectional study, routinely collected dispensing data from the Dutch Foundation of Pharmaceutical Statistics from 2012 to 2017 were used. The number of women 18 years and older, treated with one of the guideline antibiotics for uncomplicated UTI and subsequent febrile UTI were analysed annually. Proportions were calculated. Data were stratified for age categories. Failure of uncomplicated UTI treatment was defined as the dispensing of an antibiotic for febrile UTI within 14 days after the dispensing of an antibiotic for uncomplicated UTI. FINDINGS Data were available from 81% of all pharmacies in 2012 to 89% in 2017. Percentages of women dispensed nitrofurantoin were relatively stable with 87.4% in 2012 and 84.4% in 2017. Percentages of women dispensed fosfomycin increased from 5.4% in 2012 to 21.8% in 2017, whereas percentages of women dispensed trimethoprim decreased from 17.8% to 8.0%. Within age categories, the percentage of women dispensed fosfomycin increased from 12.4% in women 18-30 years old to 36.7% in women above 80 years old. Percentages of women dispensed antibiotics for febrile UTI remained stable at 5% annually. Percentages of women receiving ciprofloxacin increased from 1.9% in 2012 to 3.3% in 2017, while those receiving amoxicillin/clavulanic acid decreased from 2.9% to 1.8%. New guideline recommendations resulted in corresponding changes in dispensed antibiotics for uncomplicated UTI and subsequent febrile UTI. Drug choices differed for age categories.
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23
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Rural-urban differences in antibiotic prescribing for uncomplicated urinary tract infection. Infect Control Hosp Epidemiol 2021; 42:1437-1444. [PMID: 33622432 DOI: 10.1017/ice.2021.21] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To examine rural-urban differences in temporal trends and risk of inappropriate antibiotic use by agent and duration among women with uncomplicated urinary tract infection (UTI). DESIGN Observational cohort study. METHODS Using the IBM MarketScan Commercial Database (2010-2015), we identified US commercially insured women aged 18-44 years coded for uncomplicated UTI and prescribed an oral antibiotic agent. We classified antibiotic agents and durations as appropriate versus inappropriate based on clinical guidelines. Rural-urban status was defined by residence in a metropolitan statistical area. We used modified Poisson regression to determine the association between rural-urban status and inappropriate antibiotic receipt, accounting for patient- and provider-level characteristics. We used multivariable logistic regression to estimate trends in antibiotic use by rural-urban status. RESULTS Of 670,450 women with uncomplicated UTI, a large proportion received antibiotic prescriptions for inappropriate agents (46.7%) or durations (76.1%). Compared to urban women, rural women were more likely to receive prescriptions with inappropriately long durations (adjusted risk ratio 1.10, 95% CI, 1.10-1.10), which was consistent across subgroups. From 2011 to 2015, there was slight decline in the quarterly proportion of patients who received inappropriate agents (48.5% to 43.7%) and durations (78.3% to 73.4%). Rural-urban differences varied over time by agent (duration outcome only), geographic region, and provider specialty. CONCLUSIONS Inappropriate antibiotic prescribing is quite common for the treatment of uncomplicated UTI. Rural women are more likely to receive inappropriately long antibiotic durations. Antimicrobial stewardship interventions are needed to improve outpatient UTI antibiotic prescribing and to reduce unnecessary exposure to antibiotics, particularly in rural settings.
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Porreca A, D'Agostino D, Romagnoli D, Del Giudice F, Maggi M, Palmer K, Falabella R, De Berardinis E, Sciarra A, Ferro M, Artibani W, Mirone V, Busetto GM. The Clinical Efficacy of Nitrofurantoin for Treating Uncomplicated Urinary Tract Infection in Adults: A Systematic Review of Randomized Control Trials. Urol Int 2021; 105:531-540. [PMID: 33535221 DOI: 10.1159/000512582] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 10/25/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To provide an updated systematic review of randomized control trials (RCTs) to investigate the clinical and microbiological efficacy of nitrofurantoin compared to other antibiotics or placebo for treatment of uncomplicated urinary tract infections (uUTI). A secondary aim is to assess whether nitrofurantoin use is associated with increased side effects compared to other treatment regimens. SUMMARY The review was performed according to PRISMA guidelines. We searched 4 databases for articles published from database inception to May 6, 2020: (1) PubMed electronic database of the National Library of Medicine, (2) Web of Science, (3) Embase, and (4) Cochrane Library. Nine RCTs were selected for the review. RCTs were a mixture of double-blind, single-blind, and open-label trials. The most common comparators were trimethoprim-sulfamethoxazole and fosfomycin tromethamine. Overall study quality was poor with a high risk of bias. The clinical cure rates in nitrofurantoin ranged from 51 to 94% depending on the length of follow-up, and bacteriological cure rates ranged from 61 to 92%. Overall the evidence suggests that nitrofurantoin is at least comparable with other uUTI treatments in terms of efficacy. Patients taking nitrofurantoin reported fewer side effects than other drugs and the most commonly reported were gastrointestinal and central nervous system symptoms. Key Messages: Evidence on the clinical and bacteriological efficacy of nitrofurantoin is sparse, with a lack of new data, and hampered by high risk of bias. Although no firm conclusions can be made on the current base of evidence, the studies generally suggest that nitrofurantoin is at least comparable to other common uUTI treatments in terms of clinical and bacteriological cure. More robust research with well-designed double-blinded RCTs is needed.
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Affiliation(s)
- Angelo Porreca
- Department of Urology, Veneto Institute of Oncology (IOV), Padua, Italy
| | | | | | - Francesco Del Giudice
- Department of Urology, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Martina Maggi
- Department of Urology, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Katie Palmer
- Department of Internal Medicine and Geriatrics, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Ettore De Berardinis
- Department of Urology, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Alessandro Sciarra
- Department of Urology, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Matteo Ferro
- Department of Urology, IRCCS European Institute of Oncology (IEO), Milan, Italy
| | - Walter Artibani
- Department of Urology, Abano Terme Policlinic, Abano Terme, Italy
| | - Vincenzo Mirone
- Department of Urology, University of Naples Federico II, Naples, Italy
| | - Gian Maria Busetto
- Department of Urology and Renal Transplantation, University of Foggia Policlinico Riuniti of Foggia, Foggia, Italy,
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Rudolph A, Dahmke H, Kupferschmidt H, Burden A, Weiler S. Coadministration of tizanidine and ciprofloxacin: a retrospective analysis of the WHO pharmacovigilance database. Eur J Clin Pharmacol 2021; 77:895-902. [PMID: 33404754 PMCID: PMC8128801 DOI: 10.1007/s00228-020-02981-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 08/11/2020] [Indexed: 12/01/2022]
Abstract
PURPOSE Tizanidine, an alpha-adrenergic substance with antinociceptive and antihypertensive effects, is extensively metabolized via cytochrome P450 (CYP) 1A2. Therefore, coadministration with potent CYP1A2 inhibitors, such as ciprofloxacin, is contraindicated. However, both drugs are broadly utilized in various countries. Their concomitant use bears an inherent high risk for clinically significant symptoms, especially in multimorbid patients experiencing polypharmacy. This study aims to investigate the impact of coadministration of tizanidine and ciprofloxacin using real-world pharmacovigilance data and to raise awareness of this potentially underestimated safety issue. METHODS We conducted a retrospective study including Individual Case Safety Reports (ICSR) registered until March 1, 2017, in the World Health Organization (WHO) global database. Demographic data, drug administration information, the course of the adverse drug reaction (ADR), its severity, and outcomes were analyzed for cases reporting ciprofloxacin comedication. RESULTS In 91 (2.0%) of the identified 4192 worldwide ICSR on tizanidine, coadministration of ciprofloxacin was reported. Most of the patients were female (n = 59, 64.8%) with a median age of 54 years (range 13-85 years). The countries contributing most reports were the USA (n = 54, 59.3%) and Switzerland (n = 16, 17.6%). ADRs reported most often affected the nervous system and the cardiac function, especially with large tizanidine doses or drugs with CNS and cardiovascular depressant effects. In two cases, a fatal outcome was reported. CONCLUSION Despite the existing formal contraindication, the concomitant use of tizanidine and ciprofloxacin can be observed in real-world clinical practice. Reactions mainly affected the central nervous and the cardiovascular system resulting in potentially severe adverse effects. The concomitant use of tizanidine and ciprofloxacin should absolutely be avoided.
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Affiliation(s)
- Annette Rudolph
- Pharmacology Unit, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | | | - Hugo Kupferschmidt
- Tox Info Suisse, National Poisons Information Centre, Associated Institute of the University of Zurich, CH-8032, Zurich, Switzerland
| | - Andrea Burden
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH, Zurich, Switzerland
| | - Stefan Weiler
- Tox Info Suisse, National Poisons Information Centre, Associated Institute of the University of Zurich, CH-8032, Zurich, Switzerland. .,Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH, Zurich, Switzerland.
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26
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Pinkerton M, Bongu J, James A, Lowder J, Durkin M. A qualitative analysis of diagnostic testing, antibiotic selection, and quality improvement interventions for uncomplicated urinary tract infections. PLoS One 2020; 15:e0238453. [PMID: 32877460 PMCID: PMC7467288 DOI: 10.1371/journal.pone.0238453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 08/16/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Uncomplicated urinary tract infections (UTIs) can often be diagnosed based solely on symptoms and should be treated with a short course of narrow spectrum antibiotics. However, clinicians often order urine analyses and prescribe long courses of broad spectrum antibiotics. OBJECTIVE The objectives of our study are: 1) Understand how primary care providers and residents clinically approach UTIs and 2) to understand specific opportunities, based on provider type, to target future antibiotic stewardship interventions. DESIGN AND PARTICIPANTS We conducted semi-structured qualitative interviews of community primary care providers (n = 15) and internal medicine residents (n = 15) in St. Louis, Missouri from 2018-2019. A 5-point Likert scale was used to evaluate participant preferences for possible interventions. Interviews were transcribed, de-identified, and coded by two independent researchers using a combination inductive and deductive approach. KEY RESULTS Several common themes emerged. Both providers and residents ordered urine tests to "confirm" presence of urinary tract infections. Antibiotic prescription decisions were often based on historical practice and anecdotal experience rather than local susceptibility data or clinical practice guidelines. Community providers were more comfortable treating patients over the phone than residents and tended to prescribe longer courses of antibiotics. Both community providers and residents voiced frustrations with guidelines being difficult to easily incorporate due to length and extraneous information. Preferences for receiving and incorporating guidelines into practice varied. Both groups felt benchmarking would improve prescribing practices but had reservations about implementation. Community providers preferred pragmatic clinical decision support systems and nurse triage algorithms. Residents preferred order sets. CONCLUSIONS Significant opportunities exist to optimize urinary tract infection management among residents and community providers. Multifaceted interventions that include provider education, synthesis of guidelines, and pragmatic clinical decision support systems are needed to improve antibiotic prescribing and diagnostic testing; optimal interventions to improve UTI management may vary based on provider training level.
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Affiliation(s)
- Mark Pinkerton
- Division of Hospital Medicine, Department of Internal Medicine, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Jahnavi Bongu
- Division of Infectious Diseases, Department of Medicine, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Aimee James
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Jerry Lowder
- Division of Urogynecology and Female Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Michael Durkin
- Division of Infectious Diseases, Department of Medicine, Washington University in St. Louis, St. Louis, Missouri, United States of America
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Wattengel BA, DiTursi S, Schroeck JL, Sellick JA, Mergenhagen KA. Outpatient antimicrobial stewardship: Targets for urinary tract infections. Am J Infect Control 2020; 48:1009-1012. [PMID: 31955854 DOI: 10.1016/j.ajic.2019.12.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 12/18/2019] [Accepted: 12/18/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Urinary tract infections (UTIs) are common. Outpatient antimicrobial stewardship programs are emerging and a focused approach to UTIs is needed to help guide programs. METHODS Data were collected by retrospective chart review of outpatients using encounters from January 2005 to March 2018. Antibiotic therapy was indicated if at least one UTI symptom was present. Antibiotic therapy was appropriate if consistent with guidelines and culture results. Factors that differed significantly (P <.05) between the comparator groups were built into a multivariable logistic regression model to determine factors associated with inappropriate prescribing. RESULTS A total of 607 outpatients were included, of which approximately 68% were treated inappropriately. Inappropriate regimens consisted of 50.9% (n = 309) incorrect durations, 35.1% (n = 213) incorrect choice of antibiotic, and 12.4% (n = 75) incorrect doses. Ten percent of patients developed a reinfection within 30 days. Recurrence of UTI with the same pathogen within 30 days occurred in 5.1%. Catheter use and advanced age are both risk factors for recurrence and inappropriate treatment. CONCLUSIONS Outpatient antibiotic prescribing for UTIs is suboptimal. Stewardship programs should focus on patients with catheters and of advanced age as they are often inappropriately treated.
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Validating Use of Electronic Health Data to Identify Patients with Urinary Tract Infections in Outpatient Settings. Antibiotics (Basel) 2020; 9:antibiotics9090536. [PMID: 32854205 PMCID: PMC7558992 DOI: 10.3390/antibiotics9090536] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 08/21/2020] [Accepted: 08/24/2020] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE To validate the use of electronic algorithms based on International Classification of Diseases (ICD)-10 codes to identify outpatient visits for urinary tract infections (UTI), one of the most common reasons for antibiotic prescriptions. METHODS ICD-10 symptom codes (e.g., dysuria) alone or in addition to UTI diagnosis codes plus prescription of a UTI-relevant antibiotic were used to identify outpatient UTI visits. Chart review (gold standard) was performed by two reviewers to confirm diagnosis of UTI. The positive predictive value (PPV) that the visit was for UTI (based on chart review) was calculated for three different ICD-10 code algorithms using (1) symptoms only, (2) diagnosis only, or (3) both. RESULTS Of the 1087 visits analyzed, symptom codes only had the lowest PPV for UTI (PPV = 55.4%; 95%CI: 49.3-61.5%). Diagnosis codes alone resulted in a PPV of 85% (PPV = 84.9%; 95%CI: 81.1-88.2%). The highest PPV was obtained by using both symptom and diagnosis codes together to identify visits with UTI (PPV = 96.3%; 95%CI: 94.5-97.9%). CONCLUSIONS ICD-10 diagnosis codes with or without symptom codes reliably identify UTI visits; symptom codes alone are not reliable. ICD-10 based algorithms are a valid method to study UTIs in primary care settings.
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Bratsman A, Mathias K, Laubscher R, Grigoryan L, Rose S. Outpatient fluoroquinolone prescribing patterns before and after US FDA boxed warning. Pharmacoepidemiol Drug Saf 2020; 29:701-707. [PMID: 32390266 DOI: 10.1002/pds.5018] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 04/02/2020] [Accepted: 04/09/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Fluoroquinolones are routinely overprescribed for uncomplicated urinary tract infection (uUTI), acute sinusitis, and acute bronchitis. In 2016, the United States (US) Food and Drug Administration (FDA) updated the boxed warning on fluoroquinolones, recommending against their use as first-line agents for the routine pharmacologic management of uUTI, acute sinusitis, and acute bronchitis in patients who have other treatment options. The primary objective of this study was to determine if the 2016 expanded boxed warning was associated with decreased fluoroquinolone prescription rates for these three diagnoses. METHODS We retrospectively reviewed antibiotics prescribed at a single, large, academic outpatient center for these three diagnoses between January 2013 and May 2018. Interrupted time series analysis was used to compare the rate of fluoroquinolone prescriptions before and after the May 2016 FDA boxed warning. RESULTS A total of 10 087 antibiotic prescriptions for these three diagnoses were examined. There was no significant change in fluoroquinolone prescription rates after the FDA boxed warning. The majority of inappropriate fluoroquinolone prescriptions were given for the management of uUTI. CONCLUSION The 2016 US FDA boxed warning against fluoroquinolone use for uUTI, acute sinusitis, and acute bronchitis was not associated with a statistically significant reduction in the rate of fluoroquinolone prescriptions for these diagnoses. Additional research is needed to define how US FDA boxed warnings may be incorporated into broader antibiotic stewardship programs to decrease overuse of fluoroquinolones and avoid adverse effects of the drug class, including Clostridioides difficile infections and emergence of resistant organisms.
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Affiliation(s)
- Andrew Bratsman
- Department of Internal Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Kristen Mathias
- Department of Internal Medicine, University of Chicago, Chicago, Illinois, USA
| | - Rory Laubscher
- Office of Information Technology (OIT) Data Services, Baylor College of Medicine, Houston, Texas, USA
| | - Larissa Grigoryan
- Department of Family and Community, Baylor College of Medicine, Houston, Texas, USA
| | - Stacey Rose
- Department of Internal Medicine, Baylor College of Medicine, Houston, Texas, USA
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30
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Giancola SE, Higginbotham JM, Sutter DE, Spencer SE, Aden JK, Barsoumian AE. Improvement in adherence to antibiotic duration of therapy recommendations for uncomplicated cystitis: a quasi-experimental study. Fam Pract 2020; 37:242-247. [PMID: 31671172 DOI: 10.1093/fampra/cmz068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Acute uncomplicated cystitis is one of the most common diagnoses for which antibiotic treatment is prescribed in the outpatient setting. Despite the availability of national guidelines, there remains a wide pattern in prescriber choices for therapy. Recent data portray a picture of consistently longer durations than recommended prescribed in outpatient settings. OBJECTIVE The objective was to evaluate the effect of a system-based intervention on adherence to guideline-recommended durations of therapy for uncomplicated cystitis in the outpatient setting. METHODS This quasi-experimental study included women aged 18-64 years who were seen at five family medicine clinics at an academic medical centre and were prescribed targeted antibiotics for uncomplicated cystitis (nitrofurantoin monohydrate/macrocrystals 100 mg, trimethoprim-sulfamethoxazole 160/800 mg or ciprofloxacin 250 mg). The intervention involved revising or adding pre-filled, but modifiable, default prescribing instructions in the electronic health record (EHR) for the targeted antibiotics. We evaluated adherence to guideline-recommended duration of therapy as well as days of therapy (DOT) before and after the intervention. RESULTS A total of 787 pre-intervention and 862 post-intervention cases were included. Adherence to recommended duration of therapy increased from 29.4% to 76.3% (P < 0.01). The average DOT decreased by 23% from 6.6 to 5.1 (P < 0.01). CONCLUSION A stewardship intervention consisting of revising/adding default prescribing instructions to targeted antimicrobials in an EHR was associated with increased adherence to recommended durations of therapy for uncomplicated cystitis and reduction of unnecessary antibiotic exposure. More studies are needed to confirm effectiveness across multiple medical record platforms.
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Affiliation(s)
| | | | | | | | - James K Aden
- Department of Graduate Medical Education, Fort Sam Houston, TX, USA
| | - Alice E Barsoumian
- Infectious Disease Service, Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA
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31
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Robinson TF, Barsoumian AE, Aden JK, Giancola SE. Evaluation of the trends and appropriateness of fluoroquinolone use in the outpatient treatment of acute uncomplicated cystitis at five family practice clinics. J Clin Pharm Ther 2019; 45:513-519. [PMID: 31821580 DOI: 10.1111/jcpt.13099] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 10/08/2019] [Accepted: 11/19/2019] [Indexed: 11/29/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Despite recommendations to avoid fluoroquinolones (FQs) as a first-line treatment for uncomplicated cystitis, recent data suggest that FQs remain widely prescribed. Therefore, the objectives of this study were to evaluate the appropriateness of empiric FQ use compared to nitrofurantoin for uncomplicated cystitis and to determine whether there are any trends or predictors of empiric FQ versus nitrofurantoin use for uncomplicated cystitis. METHODS This retrospective study included women ages 19-64 years who were seen at five family medicine clinics and were prescribed targeted antibiotics (nitrofurantoin, ciprofloxacin or levofloxacin) for uncomplicated cystitis. Charts were reviewed to collect data, including symptoms, comorbidities, allergies, creatinine clearance, recent antibiotic use and urine culture data. Appropriateness of empiric selection was determined based on national guidelines and local susceptibility data. RESULTS AND DISCUSSION A total of 677 patient encounters were screened for inclusion. Of those, 567 met the inclusion criteria: 395 nitrofurantoin and 172 FQs. Treatment was considered appropriate in 86.8% and 10.5% of cases that were prescribed nitrofurantoin and FQs, respectively (P < .01). There were four independent predictors of FQ use identified by multivariate logistical regression: clinic at which the patient was treated, age, nitrofurantoin use within 90 days prior to encounter and previous urine culture within one year with an organism non-susceptible to nitrofurantoin. WHAT IS NEW AND CONCLUSION Despite recommendations against FQs for uncomplicated cystitis, they continue to be widely prescribed, and their use for this indication is often inappropriate. This highlights the need for additional interventions and education to improve use and preserve the utility of FQs.
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Affiliation(s)
- Thomas F Robinson
- Department of Pharmacy, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Alice E Barsoumian
- Infectious Disease Service, Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - James K Aden
- Department of Graduate Medical Education, Brooke Army Medical Center, Fort Sam Houston, TX, USA
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O'Keefe C, Thompson A, McKenzie D, Lee K. Concordance with antibiotic guidelines in Australian primary care: A retrospective study of prior-to-hospital therapy. Int J Clin Pract 2019; 73:e13427. [PMID: 31573741 DOI: 10.1111/ijcp.13427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 08/12/2019] [Accepted: 09/21/2019] [Indexed: 11/30/2022] Open
Abstract
Background Appropriate antibiotic prescribing improves patient outcomes and mitigates antimicrobial resistance. As the majority of antibiotics are used in the community, rational prescribing in this setting is of paramount importance. Objectives We aimed to (1) evaluate the concordance of community antibiotic prescribing with guidelines for three common infection types among patients who presented to hospital, and (2) identify relationships between guideline concordance and patient-related factors. Methods Medical records were evaluated from the Royal Hobart Hospital (Tasmania, Australia) for patients presenting with respiratory tract, urinary tract or skin and soft tissue infections within a 12-month period. Prior-to-hospital antibiotic therapy was assessed for concordance with prescribing guidelines based on presenting diagnosis. Concordance was assessed against first-line recommendations in the Australian Therapeutic Guidelines - Antibiotic, based on drug choice, dose, frequency and patient factors. Descriptive statistics were performed to address Objective 1. Multivariate logistic regressions were conducted to address Objective 2 with the following independent variables: infection type, age, allergies, diabetes status, gender and residential setting. Results A total of 285 patient records were eligible for data analysis; 28.8% (n = 82) were fully guideline concordant. The most common reason for non-concordance was inappropriate drug choice (n = 143, 50.2%). Patients with the following characteristics were less likely to receive concordant therapy: diabetes (OR = 0.3, 95% CI 0.1-0.8, P = .02) and increasing age (OR = 0.99, 95% CI 0.98-1.00, P = .04). Conclusions Almost three-quarters of patients received community-initiated antibiotic therapy that was not fully guideline concordant. Antimicrobial stewardship interventions are urgently needed to improve guideline concordance for community-initiated antibiotic therapy.
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Affiliation(s)
- Caitlan O'Keefe
- Pharmacy Department, Tasmanian Health Service, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Angus Thompson
- Division of Pharmacy, School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Duncan McKenzie
- Pharmacy Department, Tasmanian Health Service, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Kenneth Lee
- Division of Pharmacy, School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
- Faculty of Health and Medical Sciences, Division of Pharmacy, School of Allied Health, University of Western Australia, Crawley, Western Australia, Australia
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Cowart K, Worley M, Rouby NE, Sando K. Evaluation of FDA Boxed Warning on Prescribing Patterns of Fluoroquinolones for Uncomplicated Urinary Tract Infections. Ann Pharmacother 2019; 53:1192-1199. [PMID: 31319681 DOI: 10.1177/1060028019865224] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Little is known regarding the impact of the Food and Drug Administration (FDA) boxed warning on prescribing rates of fluoroquinolone (FQ) antibiotics in the outpatient setting. Objective: The primary objective of this study was to evaluate the 2016 FDA boxed warning update on FQ prescribing rates for uncomplicated urinary tract infection (uUTI). Methods: This was a single-center retrospective cohort study conducted at 6 family medicine practices, including women aged 18 to 65 years with an outpatient visit for uUTI from January 1, 2016, to December 31, 2016. Results: A total of 436 patients met inclusion. FQs were prescribed in 38% of patients before the FDA boxed warning and in 30% of patients after (8% reduction). Non-FQ prescribing had a corresponding 8% increase, comprising 62% of uUTI prescribing before the FDA boxed warning and 70% after (P = 0.08). The likelihood of being prescribed a FQ was not significantly different following release of the FDA boxed warning (adjusted odds ratio = 0.67 [95% CI = 0.41-1.10]). Variables significantly associated with an increase in FQ prescribing based on logistic regression were age ≥58 years and chronic kidney disease. Concordance of antibiotic prescribing with the Infectious Diseases Society of America clinical practice guidelines for uUTI was low, and the incidence of treatment failure was low. Conclusion and Relevance: The 2016 FDA boxed warning was not significantly associated with decreased FQ prescribing for uUTI across a large academic family medicine practice. Methods to improve education and disseminate FDA warnings in practice are needed.
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Affiliation(s)
- Kevin Cowart
- University of South Florida College of Pharmacy, Tampa, FL, USA
| | - Marylee Worley
- Nova Southeastern University College of Pharmacy, Fort Lauderdale, FL, USA
| | - Nihal El Rouby
- University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Karen Sando
- Nova Southeastern University College of Pharmacy, Fort Lauderdale, FL, USA
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Qualitative Analysis of Primary Care Provider Prescribing Decisions for Urinary Tract Infections. Antibiotics (Basel) 2019; 8:antibiotics8020084. [PMID: 31248119 PMCID: PMC6627108 DOI: 10.3390/antibiotics8020084] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 06/13/2019] [Accepted: 06/14/2019] [Indexed: 12/26/2022] Open
Abstract
Inappropriate choices and durations of therapy for urinary tract infections (UTI) are a common and widespread problem. In this qualitative study, we sought to understand why primary care providers (PCPs) choose certain antibiotics or durations of treatment and the sources of information they rely upon to guide antibiotic-prescribing decisions. We conducted semi-structured interviews with 18 PCPs in two family medicine clinics focused on antibiotic-prescribing decisions for UTIs. Our interview guide focused on awareness and familiarity with guidelines (knowledge), acceptance and outcome expectancy (attitudes), and external barriers. We followed a six-phase approach to thematic analysis, finding that many PCPs believe that fluoroquinolones achieve more a rapid and effective control of UTI symptoms than trimethoprim-sulfamethoxazole or nitrofurantoin. Most providers were unfamiliar with fosfomycin as a possible first-line agent for the treatment of acute cystitis. PCPs may be misled by advanced patient age, diabetes, and recurrent UTIs to make inappropriate choices for the treatment of acute cystitis. For support in clinical decision making, few providers relied on guidelines, preferring instead to have decision support embedded in the electronic medical record. Knowing the PCPs’ knowledge gaps and preferred sources of information will guide the development of a primary care-specific antibiotic stewardship intervention for acute cystitis.
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Concia E, Bragantini D, Mazzaferri F. Clinical evaluation of guidelines and therapeutic approaches in multi drug-resistant urinary tract infections. J Chemother 2018; 29:19-28. [PMID: 29271735 DOI: 10.1080/1120009x.2017.1380397] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Antibiotic resistance represents a real health emergency worldwide, mostly due to the lack of new antibiotics active against multidrug-resistant Enterobacteriaceae. Considering the global epidemiological situation in several infections, including urinary tract infections (UTIs), some antibiotics, such as fluoroquinolones and trimethoprim/sulphamethoxazole, can no longer be used for empiric treatment due to high resistance rates. However, some old antibiotics maintain high microbiological activity against UTI pathogens: according to many recent guidelines, fosfomycin trometamol, nitrofurantoin and pivmecillinam are recommended for the first-line treatment of uncomplicated UTIs. This article provides an overview of the therapeutic management of UTIs, especially uncomplicated and recurrent cystitis, as well as complicated UTIs such as catheter-related UTIs, and UTIs in males, post-menopausal women and diabetic patients, based on the main international guidelines.
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Affiliation(s)
- Ercole Concia
- a Infectious Diseases and Tropical Medicine Section, Department of Diagnostic and Public Health , University of Verona , Verona , Italy
| | - Damiano Bragantini
- a Infectious Diseases and Tropical Medicine Section, Department of Diagnostic and Public Health , University of Verona , Verona , Italy
| | - Fulvia Mazzaferri
- a Infectious Diseases and Tropical Medicine Section, Department of Diagnostic and Public Health , University of Verona , Verona , Italy
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Prevalence of Inappropriate Antibiotic Prescribing in Primary Care Clinics within a Veterans Affairs Health Care System. Antimicrob Agents Chemother 2018; 62:AAC.00337-18. [PMID: 29967028 DOI: 10.1128/aac.00337-18] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 06/05/2018] [Indexed: 01/12/2023] Open
Abstract
Data are needed from outpatient settings to better inform antimicrobial stewardship. In this study, a random sample of outpatient antibiotic prescriptions by primary care providers (PCPs) at our health care system was reviewed and compared to consensus guidelines. Over 12 months, 3,880 acute antibiotic prescriptions were written by 76 PCPs caring for 40,734 patients (median panel, 600 patients; range, 33 to 1,547). PCPs ordered a median of 84 antibiotic prescriptions per 1,000 patients per year. Azithromycin (25.8%), amoxicillin-clavulanate (13.3%), doxycycline (12.4%), amoxicillin (11%), fluoroquinolones (11%), and trimethoprim-sulfamethoxazole (10.6%) were prescribed most commonly. Medical records corresponding to 300 prescriptions from 59 PCPs were analyzed in depth. The most common indications for these prescriptions were acute respiratory tract infection (28.3%), urinary tract infection (23%), skin and soft tissue infection (15.7%), and chronic obstructive pulmonary disease (COPD) exacerbation (6.3%). In 5.7% of cases, no reason for the prescription was listed. No antibiotic was indicated in 49.7% of cases. In 12.3% of cases, an antibiotic was indicated, but the prescribed agent was guideline discordant. In another 14% of cases, a guideline-concordant antibiotic was given for a guideline-discordant duration. Therefore, 76% of reviewed prescriptions were inappropriate. Ciprofloxacin and azithromycin were most likely to be prescribed inappropriately. A non-face-to-face encounter prompted 34% of prescriptions. The condition for which an antibiotic was prescribed was not listed in primary or secondary diagnosis codes in 54.5% of clinic visits. In conclusion, there is an enormous opportunity to reduce inappropriate outpatient antibiotic prescriptions.
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Chastain DB, King ST, Stover KR. Rethinking urinary antibiotic breakpoints: analysis of urinary antibiotic concentrations to treat multidrug resistant organisms. BMC Res Notes 2018; 11:497. [PMID: 30029611 PMCID: PMC6053836 DOI: 10.1186/s13104-018-3599-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 07/12/2018] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE The present study analyzed whether renally eliminated antibiotics achieve sufficient urinary concentrations based on their pharmacokinetic/pharmacodynamic principles to effectively eradicate organisms deemed resistant by automated susceptibility testing. RESULTS Lower median minimum inhibitory concentrations against enterobacteriaceae were noted for ceftriaxone, cefepime, and doripenem when comparing Etest® to Vitek®. All Pseudomonas aeruginosa isolates were susceptible to cefepime, ciprofloxacin, and doripenem with both susceptibility methods, but higher median minimum inhibitory concentrations were observed with Etest®. Urine concentrations/time profiles were calculated for standard doses of ceftriaxone, cefepime, doripenem, and ciprofloxacin. The data presented in the current study suggests high urine concentrations of antibiotics may effectively eradicate bacteria which were determined to be resistant per in vitro susceptibility testing.
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Affiliation(s)
- Daniel B Chastain
- University of Georgia College of Pharmacy, 1000 Jefferson Street, Albany, GA, 31701, USA.
| | - S Travis King
- Ochsner Medical Center-New Orleans, New Orleans, LA, 70121, USA
| | - Kayla R Stover
- University of Mississippi School of Pharmacy, Jackson, MS, 39216, USA.,Division of Infectious Diseases, University of Mississippi Medical Center, Jackson, MS, 39216, USA
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Santoso BI, Surya R, Yasmin FA, Irwinda R. The awareness of urinary tract infection management in pregnant women. A qualitative study. MAJALAH OBSTETRI & GINEKOLOGI 2018. [DOI: 10.20473/mog.v25i32017.92-96] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objectives: to identify knowledge, attitude, and practice of health providers including GPs and gynecologists to the implementation of the national guideline on the treatment of UTI among pregnant women.Materials and Methods: A cross-sectional study design was used. Subjects were women who attended the International Sym-posium of UTI. Questionnaires consisting ofregarding demo-graphic characteristics, knowledge, attitude, and practice were given to the subjects. The questionnaires had been tested for valid-ity and reliability by applying the Pearson correlation and Cronbach’s alpha test. Statistical analyses were performed using SPSS 23.0 for Windows.A two-tailed p value less than 0.05 was considered to be statistically significant.Results: A total of 140 subjects were recruited in this study. Of these, 104 subjects (74.3%) returned the questionnaire, and 99 subjects (70.7%) were eligible for this study. Nine (9.1%), 69 (69.7%), and 21(21.2%) subjects had good, fair, and poor know-ledge, respectively. Sixty-five (65.7%) and 64 subjects (64.6%) showed a positive attitude and had positive practice, respectively.Conclusion: Knowledge, attitude, and practice among respon-dents are good enough, despite only a few of them have read the updated guideline. Continuous medical education through online update or symposium may be one effective method to disseminate new update in guidelines.
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Kabbara WK, Meski MM, Ramadan WH, Maaliki DS, Salameh P. Adherence to International Guidelines for the Treatment of Uncomplicated Urinary Tract Infections in Lebanon. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2018; 2018:7404095. [PMID: 29675117 PMCID: PMC5838434 DOI: 10.1155/2018/7404095] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 01/22/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The purpose of this study is to evaluate antibiotic-prescribing practices and adherence to IDSA guidelines for the treatment of uncomplicated urinary tract infections in Lebanon. METHODS This observational prospective study was conducted in 15 community pharmacies in Lebanon over 1 year in adult females. A regimen of nitrofurantoin 100 mg bid for 5 days or fosfomycin 3 grams single dose were considered appropriate. For the bivariate analysis, the chi-square test was used. RESULTS A total of 376 patients were included in this study. The prescribed antibiotic was appropriate in 35 percent of the patients. Age (more than 50 years) did not significantly affect the appropriateness of the prescribed antibiotic (p=0.508). The frequency of attacks per year (more than 3) negatively affected the choice of antibiotic (p=0.025). The dose and duration of the prescribed antibiotic was appropriate in 73 and 58 percent of the patients, respectively, with a significant inappropriate dose and duration with fluoroquinolones as compared to nitrofurantoin and fosfomycin (p < 0.001 for the dose and p=0.014 for the duration of therapy). CONCLUSIONS In an era of increasing bacterial resistance, interventions that improve physicians' prescribing practices for uncomplicated urinary tract infections are needed.
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Affiliation(s)
- Wissam K. Kabbara
- Department of Pharmacy Practice, School of Pharmacy, Lebanese American University (LAU), Byblos, Lebanon
| | - Mohamad M. Meski
- School of Pharmacy, Lebanese American University (LAU), Byblos, Lebanon
| | - Wijdan H. Ramadan
- Department of Pharmacy Practice, School of Pharmacy, Lebanese American University (LAU), Byblos, Lebanon
| | - Dina S. Maaliki
- School of Pharmacy, Lebanese American University (LAU), Byblos, Lebanon
| | - Pascale Salameh
- Faculty of Medical Sciences, Lebanese University, Hadath, Lebanon
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Antimicrobial Stewardship Efforts to Improve Management of Uncomplicated Urinary Tract Infections in the Ambulatory Care Setting: a Review. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2018. [DOI: 10.1007/s40506-018-0150-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Grigoryan L, Zoorob R, Wang H, Horsfield M, Gupta K, Trautner BW. Less workup, longer treatment, but no clinical benefit observed in women with diabetes and acute cystitis. Diabetes Res Clin Pract 2017; 129:197-202. [PMID: 28544925 DOI: 10.1016/j.diabres.2017.05.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 05/08/2017] [Indexed: 11/25/2022]
Abstract
AIMS There is a lack of evidence on the optimal approach for treating acute cystitis in women with diabetes. We performed an outpatient database study to compare management of women with and without diabetes and to assess the effect of treatment duration on early and late recurrence. METHODS We used the EPIC Clarity database (electronic medical record system) to identify all female patients aged ≥18years with acute cystitis in two family medicine clinics and a urology department. An index case was defined as the first cystitis episode during the study period (2011-2014) with follow-up data of at least 12months. Recurrence was defined as a Urinary Tract Infection (UTI) episode, plus a new prescription for an antibiotic, between 6 and 29days (early), or between 30days and 12months (late). RESULTS We included 2327 visits for cystitis representing 1845 unique patients. Women with diabetes and acute cystitis were less likely to receive urinary tests to work up cystitis, and received significantly longer treatment courses of antibiotics. There was a higher risk of early recurrence in women with treatment duration >5days (odds ratio 2.17, 95% confidence interval 1.07-4.41) in multivariate analyses. Longer treatment was not associated with late UTI recurrence. Presence of diabetes, and Charlson comorbidity score were independent determinants of late recurrence. CONCLUSIONS Longer treatment of cystitis was not associated with lower recurrence rates. This calls into question whether many episodes of diabetic cystitis may be managed with a short course of antibiotics, as for uncomplicated disease.
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Affiliation(s)
- Larissa Grigoryan
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA.
| | - Roger Zoorob
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Haijun Wang
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Matthew Horsfield
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Kalpana Gupta
- Section of Infectious Diseases, Department of Medicine, Boston Veterans Affairs Healthcare System and Boston University School of Medicine, Boston, MA, USA
| | - Barbara W Trautner
- Houston VA Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA; Section of Infectious Diseases, Departments of Medicine and Surgery, Baylor College of Medicine, Houston, TX, USA
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Tchesnokova V, Avagyan H, Rechkina E, Chan D, Muradova M, Haile HG, Radey M, Weissman S, Riddell K, Scholes D, Johnson JR, Sokurenko EV. Bacterial clonal diagnostics as a tool for evidence-based empiric antibiotic selection. PLoS One 2017; 12:e0174132. [PMID: 28350870 PMCID: PMC5369764 DOI: 10.1371/journal.pone.0174132] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 02/24/2017] [Indexed: 01/03/2023] Open
Abstract
Despite the known clonal distribution of antibiotic resistance in many bacteria, empiric (pre-culture) antibiotic selection still relies heavily on species-level cumulative antibiograms, resulting in overuse of broad-spectrum agents and excessive antibiotic/pathogen mismatch. Urinary tract infections (UTIs), which account for a large share of antibiotic use, are caused predominantly by Escherichia coli, a highly clonal pathogen. In an observational clinical cohort study of urgent care patients with suspected UTI, we assessed the potential for E. coli clonal-level antibiograms to improve empiric antibiotic selection. A novel PCR-based clonotyping assay was applied to fresh urine samples to rapidly detect E. coli and the urine strain's clonotype. Based on a database of clonotype-specific antibiograms, the acceptability of various antibiotics for empiric therapy was inferred using a 20%, 10%, and 30% allowed resistance threshold. The test's performance characteristics and possible effects on prescribing were assessed. The rapid test identified E. coli clonotypes directly in patients' urine within 25-35 minutes, with high specificity and sensitivity compared to culture. Antibiotic selection based on a clonotype-specific antibiogram could reduce the relative likelihood of antibiotic/pathogen mismatch by ≥ 60%. Compared to observed prescribing patterns, clonal diagnostics-guided antibiotic selection could safely double the use of trimethoprim/sulfamethoxazole and minimize fluoroquinolone use. In summary, a rapid clonotyping test showed promise for improving empiric antibiotic prescribing for E. coli UTI, including reversing preferential use of fluoroquinolones over trimethoprim/sulfamethoxazole. The clonal diagnostics approach merges epidemiologic surveillance, antimicrobial stewardship, and molecular diagnostics to bring evidence-based medicine directly to the point of care.
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Affiliation(s)
- Veronika Tchesnokova
- Department of Microbiology, University of Washington School of Medicine, Seattle, WA, United States of America
| | - Hovhannes Avagyan
- Department of Microbiology, University of Washington School of Medicine, Seattle, WA, United States of America
- Kaiser Permanente Washington, Seattle, WA, United States of America
| | - Elena Rechkina
- Kaiser Permanente Washington, Seattle, WA, United States of America
- ID Genomics, Inc., Seattle, WA, United States of America
| | - Diana Chan
- Department of Microbiology, University of Washington School of Medicine, Seattle, WA, United States of America
| | - Mariya Muradova
- Department of Microbiology, University of Washington School of Medicine, Seattle, WA, United States of America
| | - Helen Ghirmai Haile
- Department of Microbiology, University of Washington School of Medicine, Seattle, WA, United States of America
| | - Matthew Radey
- Department of Microbiology, University of Washington School of Medicine, Seattle, WA, United States of America
| | - Scott Weissman
- Children’s Hospital, Seattle, WA, United States of America
| | - Kim Riddell
- Kaiser Permanente Washington, Seattle, WA, United States of America
- * E-mail: (KR); (SD); (EVS)
| | - Delia Scholes
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America
- * E-mail: (KR); (SD); (EVS)
| | - James R. Johnson
- VA Medical Center and University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Evgeni V. Sokurenko
- Department of Microbiology, University of Washington School of Medicine, Seattle, WA, United States of America
- Kaiser Permanente Washington, Seattle, WA, United States of America
- * E-mail: (KR); (SD); (EVS)
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Kranz J, Helbig S, Mandraka F, Schmidt S, Naber KG. The revival of old antibiotics for treatment of uncomplicated urinary tract infections in the era of antibiotic stewardship. Curr Opin Urol 2017; 27:127-132. [DOI: 10.1097/mou.0000000000000365] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lob SH, Nicolle LE, Hoban DJ, Kazmierczak KM, Badal RE, Sahm DF. Susceptibility patterns and ESBL rates of Escherichia coli from urinary tract infections in Canada and the United States, SMART 2010-2014. Diagn Microbiol Infect Dis 2016; 85:459-65. [PMID: 27306116 DOI: 10.1016/j.diagmicrobio.2016.04.022] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 04/25/2016] [Accepted: 04/30/2016] [Indexed: 01/28/2023]
Abstract
Increasing antimicrobial resistance in urinary tract infections (UTI) is a concern. To evaluate resistance trends, 3498 Escherichia coli UTI isolates were collected from 2010 to 2014 in the Study for Monitoring Antimicrobial Resistance Trends (SMART) in Canada and United States (US). ESBL phenotype and susceptibility were determined using CLSI microdilution and breakpoints. US ESBL rates increased in 2010-2014 (7.8-18.3%, P < 0.0001), especially among hospital-associated (HA) infections, males, and older patients (≥65 years). Overall, ESBL rates in Canada showed no significant trend (10.4-13.0%. P = 0.079), and were lower than US rates in recent years, but increased significantly among community-associated (CA) infections, females, and older patients. In the US, but not Canada, susceptibility to cephalosporins and fluoroquinolones among 2013-2014 isolates was significantly lower in isolates from HA than CA UTI, males than females, and ≥65- than <65-year-olds. These observations confirm increasing resistance in E. coli. Subgroup analyses like these may help direct empirical therapy.
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Affiliation(s)
- Sibylle H Lob
- International Health Management Associates, Inc., Schaumburg, IL, USA.
| | - Lindsay E Nicolle
- Department of Internal Medicine and Department of Medical Microbiology and Infectious Diseases, School of Medicine, University of Manitoba, Winnipeg, Canada
| | - Daryl J Hoban
- International Health Management Associates, Inc., Schaumburg, IL, USA
| | | | - Robert E Badal
- International Health Management Associates, Inc., Schaumburg, IL, USA
| | - Daniel F Sahm
- International Health Management Associates, Inc., Schaumburg, IL, USA
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