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Tyagi P, Tyagi S, Stewart L, Glickman S. SWOT and Root Cause Analyses of Antimicrobial Resistance to Oral Antimicrobial Treatment of Cystitis. Antibiotics (Basel) 2024; 13:328. [PMID: 38667004 PMCID: PMC11047466 DOI: 10.3390/antibiotics13040328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 04/01/2024] [Accepted: 04/02/2024] [Indexed: 04/29/2024] Open
Abstract
Nearly 150 million cases of urinary tract infections (UTIs) are reported each year, of which uncomplicated cystitis triggers > 25% of outpatient prescriptions of oral antimicrobial treatment (OAT). OAT aids immune cells infiltrating the urothelium in eliminating uropathogens capable of invading the urothelium and surviving hyperosmotic urine. This self-evident adaptability of uropathogens and the short interval between the introduction of Penicillin and the first report of antimicrobial resistance (AMR) implicate AMR as an evolutionary conserved heritable trait of mutant strains selected by the Darwinian principle to survive environmental threats through exponential proliferation. Therefore, AMR can only be countered by antimicrobial stewardship (AMS) following the principle of the five Ds-drug, dose, duration, drug route, and de-escalation. While convenient to administer, the onset of the minimum inhibitory concentration (MIC) for OAT in urine leaves a window of opportunity for uropathogens to survive the first contact with an antimicrobial and arm their descendant colonies with AMR for surviving subsequent higher urine antimicrobial levels. Meanwhile, the initial dose of intravesical antimicrobial treatment (IAT) may be well above the MIC. Therefore, the widespread clinical use of OAT for cystitis warrants an analysis of the strengths, weaknesses, opportunity, and threats (SWOTs) and a root cause analysis of the AMR associated with OAT and IAT.
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Affiliation(s)
- Pradeep Tyagi
- Department of Urology, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Shachi Tyagi
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA;
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Nero A, Weber M, Reveles KR, Carreno JJ. Population based cohort to examine association between geospatial antibiotic factors and urinary tract infection outcomes. Am J Infect Control 2023; 51:1017-1022. [PMID: 36736381 DOI: 10.1016/j.ajic.2023.01.011] [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] [Received: 10/07/2022] [Revised: 01/10/2023] [Accepted: 01/12/2023] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Urinary tract infections (UTIs) pose a significant health care burden. Outpatient antibiotic geospatial factors (eg, geographic prescribing and geographic resistance) may be associated with inpatient outcomes. This study examined the relationship between these factors, severe UTI, and hospitalization for severe UTI. METHODS The first cohort included hospitalized, female, Medicare beneficiaries, aged >50 years. The primary outcome was severe UTI (defined as CSS diagnosis code of 159 with an APR-DRG severity of illness code of 3 or 4). The association between geospatial first-line prescribing (FLP) and severe UTI was assessed. The second cohort examined the association between these geospatial FLP and risk of hospitalization with severe UTI. Multivariable regression was used to produce adjusted odds ratios and adjusted risk ratios. RESULTS In the first cohort (n = 14,474), low FLP was not associated with severe UTI (P = .87) in univariable analysis. In multivariable analysis, low FLP was associated with severe UTI was (aOR: 1.08 [95% CI 1.00, 1.16]). In the second cohort (n = 2,972,174), the admission rate was 47.0 and 49.8 per 10,000 (low FLP vs high FLP, respectively [P < .001]). The aRR for admission was 1.26 (95% CI 1.14, 1.39) in areas with low FLP. CONCLUSIONS This study suggests that geospatial antibiotic factors may influence inpatient outcomes in women aged >50 with UTI. Further research is needed to corroborate our findings.
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Affiliation(s)
- Alexa Nero
- Albany College of Pharmacy and Health Sciences, Albany, NY
| | - Mckayla Weber
- Albany College of Pharmacy and Health Sciences, Albany, NY
| | - Kelly R Reveles
- The University of Texas at Austin, College of Pharmacy, Austin, TX; University of Texas Health San Antonio, Pharmacotherapy Education and Research Center, San Antonio, TX
| | - Joseph J Carreno
- Albany College of Pharmacy and Health Sciences, Department of Pharmacy Practice, Albany, NY.
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Leroy R, Bourgeois J, Verleye L, Carvalho JC, Eloot A, Cauwels R, Declerck D. Are systemic antibiotics indicated in children presenting with an odontogenic abscess in the primary dentition? A systematic review of the literature. Clin Oral Investig 2021; 25:2537-2544. [PMID: 33791867 DOI: 10.1007/s00784-021-03862-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 02/24/2021] [Indexed: 12/28/2022]
Abstract
OBJECTIVES This systematic review aimed to assess (1) whether systemic antibiotics are beneficial or harmful in healthy children who present with an odontogenic abscess in the primary dentition with or without systemic involvement and (2) if antibiotics are beneficial, which type, dosage and duration are the most effective. MATERIALS AND METHODS Electronic databases (Medline, Embase, and the Cochrane Library) were screened from 1948 up to August 2020. No filters with respect to study design were applied. Outcomes of interest included pain, swelling, pain relief, adverse effects, signs of infection, quality-of-life measurements and medication required for pain relief. RESULTS Altogether, 352 titles and abstracts were screened for eligibility; of these, 19 were selected for full text assessment. All were excluded because none of them fulfilled the inclusion criteria and addressed the (adjunctive) use of antibiotics in children who present with an odontogenic abscess in the primary dentition. CONCLUSIONS At present, there is no single randomised or non-randomised clinical study evaluating the effectiveness and harms of systemic antibiotics administered in children who present with an odontogenic abscess in the primary dentition. CLINICAL RELEVANCE There is no clinical evidence to support nor to refute the use of antibiotics in children who present with an odontogenic abscess in the primary dentition without signs of local spread or systemic involvement. Given this lack of scientific evidence, the use of antibiotics cannot be recommended in these children. Well-designed clinical trials are indicated to fully understand the impact and necessity of antibiotics in these situations.
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Affiliation(s)
- Roos Leroy
- Belgian Health Care Knowledge Centre (KCE), Kruidtuinlaan 55, B-1000, Brussels, Belgium.
| | - Jolyce Bourgeois
- Belgian Health Care Knowledge Centre (KCE), Kruidtuinlaan 55, B-1000, Brussels, Belgium
| | - Leen Verleye
- Belgian Health Care Knowledge Centre (KCE), Kruidtuinlaan 55, B-1000, Brussels, Belgium
| | - Joana C Carvalho
- Faculty of Medicine and Dentistry, UCLouvain, Av. Hippocrate 10, B-1200, Brussels, Belgium
| | - Anouk Eloot
- Private Dental Practice, Emiel Verhaerenlaan 37, B-9050, Gentbrugge, Belgium
| | - Rita Cauwels
- Department of Oral Health Sciences, UGent, C. Heymanslaan 10, B-9000, Ghent, Belgium
| | - Dominique Declerck
- Department of Oral Health Sciences, Population Studies in Oral Health, KU Leuven, Kapucijnenvoer 7/a-box 7001, B-3000, Leuven, Belgium
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Amayun I. Adherence to recent antibiotic guidelines for acute uncomplicated cystitis. J Am Assoc Nurse Pract 2021; 33:879-885. [PMID: 33731550 DOI: 10.1097/jxx.0000000000000526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 09/02/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND In 2017, the Centers for Disease Control and Prevention (CDC) published guidelines for treating acute uncomplicated cystitis (AUC) with nitrofurantoin (NTF), sulfamethoxazole-trimethoprim (SMX-TMP), or fosfomycin (FM) as appropriate first-line agents. OBJECTIVE To evaluate whether provider adherence to prescribing NTF, SMX-TMP, or FM has improved since the 2017 CDC guidelines were released, and to examine outcomes relative to the use of prescribing guidelines. DATA SOURCE A literature review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis, and a systematic search for articles was conducted in the PubMed and Cochrane search engines using Boolean operators (AND, OR). The searches resulted in 56 published studies. After application of exclusion criteria, 11 peer-reviewed articles were ultimately included in this review. CONCLUSION The review showed prescribers' increasing efforts to adhering to antibiotic prescription guidelines for treating AUC, such as the 2017 CDC guidelines. The studies presented strong evidence that NTF, SMX-TMP, and FM are equally efficacious and cost-effective for treating AUC without concern for antibiotic resistance. Studies that referenced prescription guidelines and local antibiotic resistance yielded desired patient outcomes in bacterial and symptom resolution and cost-effectiveness. IMPLICATIONS FOR PRACTICE This article provides evidence and a platform for nurse practitioners to initiate collaborative efforts for structured AUC treatment guidelines in primary health care. To increase prescription adherence, electronic health records could be designed that would prompt prescribers to use updated local antibiotic resistance information and to use NTF, SMT-TMX, and FM as first-line agents.
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Affiliation(s)
- Ira Amayun
- University of San Francisco School of Nursing and Health Professions, San Franciso, California
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Lin K, Zahlanie Y, Ortwine JK, Mang NS, Wei W, Brown LS, Prokesch BC. Decreased Outpatient Fluoroquinolone Prescribing Using a Multimodal Antimicrobial Stewardship Initiative. Open Forum Infect Dis 2020; 7:ofaa182. [PMID: 32548204 PMCID: PMC7284006 DOI: 10.1093/ofid/ofaa182] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 05/15/2020] [Indexed: 12/18/2022] Open
Abstract
Background Fluoroquinolones are antibiotics prescribed in the outpatient setting, though they have serious side effects. This study evaluates the impact of stewardship interventions on total and inappropriate prescribing of fluoroquinolones in outpatient settings in a large county hospital and health system. Methods In an effort to decrease inappropriate outpatient fluoroquinolone usage, a multimodal antimicrobial stewardship initiative was implemented in November 2016. Education regarding the risks, benefits, and appropriate uses of fluoroquinolones was provided to providers in different outpatient settings, Food and Drug Administration warnings were added to all oral fluoroquinolone orders, an outpatient order set for cystitis treatment was created, and fluoroquinolone susceptibilities were suppressed when appropriate. Charts from October 2016, 2017, and 2018 were retrospectively reviewed if the patient encounter occurred in primary care clinics, emergency departments, or urgent care centers within Parkland Health & Hospital System and a fluoroquinolone was prescribed. Inappropriate use was defined as a fluoroquinolone prescription for cystitis, bronchitis, or sinusitis in a patient without a history of Pseudomonas aeruginosa or multidrug-resistant organisms and without drug allergies that precluded use of other oral antibiotics. Results Total fluoroquinolone prescriptions per 1000 patient visits decreased significantly by 39% (P < .01), and inappropriate fluoroquinolone use decreased from 53% to 34% (P < .01). More than 90% of inappropriate fluoroquinolone prescriptions were given for cystitis, while bronchitis and sinusitis accounted for only 4.4% and 1.6% of inappropriate indications, respectively. Conclusion A multimodal stewardship initiative appears to effectively reduce both total and inappropriate outpatient fluoroquinolone prescriptions.
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Affiliation(s)
- Kevin Lin
- Department of Pharmacy, Parkland Health & Hospital System, Dallas, Texas, USA
| | - Yorgo Zahlanie
- Division of Infectious Diseases, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jessica K Ortwine
- Department of Pharmacy, Parkland Health & Hospital System, Dallas, Texas, USA.,Division of Infectious Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Norman S Mang
- Department of Pharmacy, Parkland Health & Hospital System, Dallas, Texas, USA.,Division of Infectious Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Wenjing Wei
- Department of Pharmacy, Parkland Health & Hospital System, Dallas, Texas, USA.,Division of Infectious Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - L Steven Brown
- Department of Health System Research, Parkland Health & Hospital System, Dallas, Texas, USA
| | - Bonnie C Prokesch
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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