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Sánchez X, Latacunga A, Cárdenas I, Jimbo-Sotomayor R, Escalante S. Antibiotic prescription patterns in patients with suspected urinary tract infections in Ecuador. PLoS One 2023; 18:e0295247. [PMID: 38033109 PMCID: PMC10688952 DOI: 10.1371/journal.pone.0295247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 11/20/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Urinary tract infections (UTI) are among the most common cause to prescribe antibiotics in primary care. Diagnosis is based on the presence of clinical symptoms in combination with the results of laboratory tests. Antibiotic therapy is the primary approach to the treatment of UTIs; however, some studies indicate that therapeutics in UTIs may be suboptimal, potentially leading to therapeutic failure and increased bacterial resistance. METHODS This study aimed to analyze the antibiotic prescription patterns in adult patients with suspected UTIs and to evaluate the appropriateness of the antibiotic prescription. This is a cross-sectional study of patients treated in outpatient centers and in a second-level hospital of the Ministry of Public Health (MOPH) in a city in Ecuador during 2019. The International Classification of Disease Tenth Revision (ICD-10) was used for the selection of the acute UTI cases. The patients included in this study were those treated by family, emergency, and internal medicine physicians. RESULTS We included a total of 507 patients in the analysis and 502 were prescribed antibiotics at first contact, constituting an immediate antibiotic prescription rate of 99.01%. Appropriate criteria for antibiotic prescription were met in 284 patients, representing an appropriate prescription rate of 56.02%. Less than 10% of patients with UTI had a urine culture. The most frequently prescribed antibiotics were alternative antibiotics (also known as second-line antibiotics), such as ciprofloxacin (50.39%) and cephalexin (23.55%). Factors associated with inappropriate antibiotic prescribing for UTIs were physician age over forty years, OR: 2.87 (95% CI, 1.65-5.12) p<0.0001, medical care by a general practitioner, OR: 1.89 (95% CI, 1.20-2.99) p = 0.006, not using point-of-care testing, OR: 1.96 (95% CI, 1.23-3.15) p = 0.005, and care at the first level of health, OR: 15.72 (95% CI, 8.57-30.88) p<0.0001. CONCLUSIONS The results of our study indicate an appropriate prescription rate of 56.02%. Recommended antibiotics such as nitrofurantoin and fosfomycin for UTIs are underutilized. The odds for inappropriate antibiotic prescription were 15.72 times higher at the first level of care compared to the second. Effective strategies are needed to improve the diagnosis and treatment of UTIs.
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Affiliation(s)
- Xavier Sánchez
- Centro de Investigación Para la Salud en América Latina (CISeAL), Facultad de Medicina, Pontificia Universidad Católica del Ecuador (PUCE), Quito, Ecuador
- Community and Primary Care Research Group – Ecuador (CPCRG-E), Quito, Ecuador
| | - Alicia Latacunga
- Postgrado de Medicina Familiar y Comunitaria, Pontificia Universidad Católica del Ecuador (PUCE), Quito, Ecuador
| | - Iván Cárdenas
- Postgrado de Medicina Familiar y Comunitaria, Pontificia Universidad Católica del Ecuador (PUCE), Quito, Ecuador
| | - Ruth Jimbo-Sotomayor
- Centro de Investigación Para la Salud en América Latina (CISeAL), Facultad de Medicina, Pontificia Universidad Católica del Ecuador (PUCE), Quito, Ecuador
- Community and Primary Care Research Group – Ecuador (CPCRG-E), Quito, Ecuador
| | - Santiago Escalante
- Centro de Investigación Para la Salud en América Latina (CISeAL), Facultad de Medicina, Pontificia Universidad Católica del Ecuador (PUCE), Quito, Ecuador
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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: 32] [Impact Index Per Article: 10.7] [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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3
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McIsaac W, Kukan S, Huszti E, Szadkowski L, O'Neill B, Virani S, Ivers N, Lall R, Toor N, Shah M, Alvi R, Bhatt A, Nakamachi Y, Morris AM. A pragmatic randomized trial of a primary care antimicrobial stewardship intervention in Ontario, Canada. BMC FAMILY PRACTICE 2021; 22:185. [PMID: 34525972 PMCID: PMC8442308 DOI: 10.1186/s12875-021-01536-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 09/01/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND More than 90% of antibiotics are prescribed in primary care, but 50% may be unnecessary. Reducing unnecessary antibiotic overuse is needed to limit antimicrobial resistance. We conducted a pragmatic trial of a primary care provider-focused antimicrobial stewardship intervention to reduce antibiotic prescriptions in primary care. METHODS Primary care practitioners from six primary care clinics in Toronto, Ontario were assigned to intervention or control groups to evaluate the effectiveness of a multi-faceted intervention for reducing antibiotic prescriptions to adults with respiratory and urinary tract infections. The intervention included provider education, clinical decision aids, and audit and feedback of antibiotic prescribing. The primary outcome was total antibiotic prescriptions for these infections. Secondary outcomes were delayed prescriptions, prescriptions longer than 7 days, recommended antibiotic use, and outcomes for individual infections. Generalized estimating equations were used to estimate treatment effects, adjusting for clustering by clinic and baseline differences. RESULTS There were 1682 encounters involving 54 primary care providers from January until May 31, 2019. In intervention clinics, the odds of any antibiotic prescription was reduced 22% (adjusted Odds Ratio (OR) = 0.78; 95% Confidence Interval (CI) = 0.64.0.96). The odds that a delay in filling a prescription was recommended was increased (adjusted OR=2.29; 95% CI=1.37, 3.83), while prescription durations greater than 7 days were reduced (adjusted OR=0.24; 95% CI=0.13, 0.43). Recommended antibiotic use was similar in control (85.4%) and intervention clinics (91.8%, p=0.37). CONCLUSIONS A community-based, primary care provider-focused antimicrobial stewardship intervention was associated with a reduced likelihood of antibiotic prescriptions for respiratory and urinary infections, an increase in delayed prescriptions, and reduced prescription durations. TRIAL REGISTRATION clinicaltrials.gov ( NCT03517215 ).
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Affiliation(s)
- Warren McIsaac
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada.
- Ray D. Wolfe Department of Family Medicine, Mount Sinai Hospital, Sinai Health, 60 Murray St, Toronto, ON, M5T 3L9, Canada.
| | - Sahana Kukan
- Ray D. Wolfe Department of Family Medicine, Mount Sinai Hospital, Sinai Health, 60 Murray St, Toronto, ON, M5T 3L9, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Canada
| | - Leah Szadkowski
- Biostatistics Research Unit, University Health Network, Toronto, Canada
| | - Braden O'Neill
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Sophia Virani
- Ray D. Wolfe Department of Family Medicine, Mount Sinai Hospital, Sinai Health, 60 Murray St, Toronto, ON, M5T 3L9, Canada
| | - Noah Ivers
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Department of Family Medicine, and Women's College Research Institute, Women's College Hospital, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Rosemarie Lall
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Platinum Medical, Scarborough Health Network Teaching Unit, Toronto, Canada
| | - Navsheer Toor
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Southlake Academic Family Health Team, Southlake Regional Health Centre, Newmarket, Toronto, Ontario, Canada
| | - Mruna Shah
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- West Durham Family Health Team, Pickering, Toronto, Ontario, Canada
| | - Ruby Alvi
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Summerville Family Health Team, Mississauga, Ontario, Canada
| | - Aashka Bhatt
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | - Yoshiko Nakamachi
- Antimicrobial Stewardship Program, University Health Network, Toronto, Canada
| | - Andrew M Morris
- Antimicrobial Stewardship Program, University Health Network, Toronto, Canada
- Department of Medicine, Division of Infectious Diseases, Sinai Health, University Health Network, and University of Toronto, Toronto, Canada
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Allerton F, Pouwels KB, Bazelle J, Caddy S, Cauvin A, De Risio L, Swann J, Warland J, Kent A. Prospective trial of different antimicrobial treatment durations for presumptive canine urinary tract infections. BMC Vet Res 2021; 17:299. [PMID: 34488771 PMCID: PMC8422737 DOI: 10.1186/s12917-021-02974-y] [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: 02/02/2021] [Accepted: 07/20/2021] [Indexed: 12/03/2022] Open
Abstract
Background Avoidance of unnecessary antimicrobial administration is a key tenet of antimicrobial stewardship; knowing the optimal duration of therapy obviates over-treatment. However, little research has been performed to establish course lengths for common canine infections. In clinical practice, antimicrobial therapy is frequently prescribed in dogs presenting lower urinary tract signs (haematuria, pollakiuria and dysuria/stranguria). The proposed length of treatment in International Consensus guidelines has decreased with each iteration, but these recommendations remain arbitrary and largely extrapolated from experience in people. Methods The objective of this prospective, multi-centre study is to find the shortest course duration that is non-inferior to the standard duration of 7 days of amoxicillin/clavulanate in terms of clinical outcomes for female dogs with lower urinary tract signs consistent with a urinary tract infection. An electronic data capture platform will be used by participating veterinarians working in clinical practice in the United Kingdom. Eligible dogs must be female, aged between 6 months and 10 years and have lower urinary tract signs of up to seven days’ duration. Enrolment will be offered in cases where the case clinician intends to prescribe antimicrobial therapy. Automatic pseudo-randomisation to treatment group will be based on the day of presentation (Monday-Friday); all antimicrobial courses will be completed on the Sunday after presentation generating different treatment durations. Follow-up data will be collected 1, 8 and 22–26 days after completion of the antimicrobial course to ensure effective safety netting, and to monitor short-term outcome and recurrence rates. Informed owner consent will be obtained in all cases. The study is approved by the Ethical Review Board of the University of Nottingham and has an Animal Test Certificate from the Veterinary Medicine’s Directorate. Discussion This study has been designed to mirror current standards of clinical management; conclusions should therefore, be widely applicable and guide practising veterinarians in their antimicrobial decision-making process. A duration-response curve will be created allowing determination of the optimal treatment duration for the management of female dogs with lower urinary tract signs. It is hoped that these results will contribute valuable information to improve future antimicrobial stewardship as part of a wider one-health perspective. Supplementary Information The online version contains supplementary material available at 10.1186/s12917-021-02974-y.
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Affiliation(s)
- Fergus Allerton
- Willows Veterinary Centre and Referral Service; part of Linnaeus Veterinary Limited, Highlands Road, Shirley, Solihull, UK.
| | - Koen B Pouwels
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial, Oxford, UK.,Resistance at University of Oxford in partnership with Public Health England, Oxford, UK
| | - Julien Bazelle
- Davies Veterinary Specialists; part of Linnaeus Veterinary Limited, Manor Farm Business Park, Higham Gobion, Hitchin, UK
| | - Sarah Caddy
- Cambridge Institute for Therapeutic Immunology and Infectious Disease, Jeffery Cheah Biomedical Centre, Puddicomb Way, Cambridge Biomedical Campus, Cambridge, UK
| | | | - Luisa De Risio
- Linnaeus Veterinary Limited, Friars gate, Shirley, Solihull, UK
| | - James Swann
- Columbia Stem Cell Initiative, Columbia University, 650 West 168th Street, NY, 10032, New York, USA
| | - James Warland
- Wellcome-MRC Cambridge Stem Cell Institute, Jeffrey Cheah Biomedical Centre, University of Cambridge, Puddicombe Way, Cambridge, UK
| | - Andrew Kent
- Willows Veterinary Centre and Referral Service; part of Linnaeus Veterinary Limited, Highlands Road, Shirley, Solihull, UK
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Bezruk VV, Bezruk TO, Godovanets OS, Sheremet MI, Yurniuk SV, Velia MI, Makarova OV, Yurkiv OI, Maksymiv OO. Peculiarities of the regional dynamics of the prevalence and incidence of cystitis in children. J Med Life 2021; 14:210-215. [PMID: 34104244 PMCID: PMC8169140 DOI: 10.25122/jml-2020-0121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
In a child, cystitis (non-specific microbial inflammation of the mucous membrane of the bladder) is considered to be a dangerous disease; the prolongation of the process is usually associated with a delayed diagnosis. The aim of this work was to analyze the health status of the child population of the Chernivtsi region, especially the dynamics of the prevalence and incidence of cystitis. The official statistical data have been studied (reports on the state of medical care for children in the Chernivtsi region and data from the Center of Medical Statistics of the Ministry of Healthcare from 2006 to 2017); information-analytical and statistical methods have been used for the purpose of this study. Attention should be drawn to the significantly high prevalence of cystitis among children aged 15–17 years, especially in the Chernivtsi region as during period I (8.7±0.6 vs. 4.3±0.3 in Ukraine) and II (11.7±1.0 and 5.7±0.4, respectively, per 1000 people). Moreover, over the years, the growth of indicators acquires intensity, while this process is more than twice as pronounced in Chernivtsi. Thus, the growth rate was 65.0% in 2006–2011 and 90.3% in 2012–2017 vs. 27.2% and 32.8% in Ukraine, respectively. The identified data indicate the need to provide specialized care to children with infectious and inflammatory diseases of the urinary system of the Chernivtsi region and the need to improve regional clinical routes of patients with infectious and inflammatory diseases of the urinary system.
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Affiliation(s)
| | - Tetyana Oleksandrivna Bezruk
- Department of Internal Medicine and Infectious Diseases, Bukovinian State Medical University, Chernivtsi, Ukraine
| | - Oleksii Serhiiovych Godovanets
- Department of Pediatrics, Neonatology and Perinatology Medicine, Bukovinian State Medical University, Chernivtsi, Ukraine
| | | | | | | | - Olena Viktorivna Makarova
- Department of Care for Patients and Higher Nursing Education, Bukovinian State Medical University, Chernivtsi, Ukraine
| | - Oksana Ivanivna Yurkiv
- Department of Care for Patients and Higher Nursing Education, Bukovinian State Medical University, Chernivtsi, Ukraine
| | - Oleh Olehovych Maksymiv
- Department of Orthopedic Dentistry, Bukovinian State Medical University, Chernivtsi, Ukraine
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6
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McIsaac WJ, Senthinathan A, Moineddin R, Nakamachi Y, Dresser L, McIntyre M, Singh S, De Oliveira N, Tannenbaum D, Bloom J, Lemieux C, Marr P, Levy M, Mitri M, Walji S, Kukan S, Morris AM. Development and evaluation of a primary care antimicrobial stewardship program (PC-ASP) in Toronto, Ontario, Canada. JOURNAL OF THE ASSOCIATION OF MEDICAL MICROBIOLOGY AND INFECTIOUS DISEASE CANADA = JOURNAL OFFICIEL DE L'ASSOCIATION POUR LA MICROBIOLOGIE MEDICALE ET L'INFECTIOLOGIE CANADA 2021; 6:32-48. [PMID: 36340211 PMCID: PMC9612432 DOI: 10.3138/jammi-2020-0021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 10/06/2020] [Indexed: 06/16/2023]
Abstract
BACKGROUND Effective community-based antimicrobial stewardship programs (ASPs) are needed because 90% of antimicrobials are prescribed in the community. A primary care ASP (PC-ASP) was evaluated for its effectiveness in lowering antibiotic prescriptions for six common infections. METHODS A multi-faceted educational program was assessed using a before-and-after design in four primary care clinics from 2015 through 2017. The primary outcome was the difference between control and intervention clinics in total antibiotic prescriptions for six common infections before and after the intervention. Secondary outcomes included changes in condition-specific antibiotic use, delayed antibiotic prescriptions, prescriptions exceeding 7 days duration, use of recommended antibiotics, and emergency department visits or hospitalizations within 30 days. Multi-method models adjusting for demographics, case mix, and clustering by physician were used to estimate treatment effects. RESULTS Total antibiotic prescriptions in control and intervention clinics did not differ (difference in differences = 1.7%; 95% CI -12.5% to 15.9%), nor did use of delayed prescriptions (-5.2%; 95% CI -24.2% to 13.8%). Prescriptions for longer than 7 days were significantly reduced (-21.3%; 95% CI -42.5% to -0.1%). However, only 781 of 1,777 encounters (44.0%) involved providers who completed the ASP education. Where providers completed the education, delayed prescriptions increased 17.7% (p = 0.06), and prescriptions exceeding 7 days duration declined (-27%; 95% CI -48.3% to -5.6%). Subsequent emergency department visits and hospitalizations did not increase. CONCLUSIONS PC-ASP effectiveness on antibiotic use was variable. Shorter prescription durations and increased use of delayed prescriptions were adopted by engaged primary care providers.
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Affiliation(s)
- Warren J McIsaac
- Ray D. Wolfe Department of Family Medicine, Sinai Health, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Arrani Senthinathan
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Rahim Moineddin
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Yoshiko Nakamachi
- Antimicrobial Stewardship Program, University Health Network, Toronto, Ontario, Canada
| | - Linda Dresser
- Antimicrobial Stewardship Program, University Health Network, Toronto, Ontario, Canada
- Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Mark McIntyre
- Antimicrobial Stewardship Program, University Health Network, Toronto, Ontario, Canada
- Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Suzanne Singh
- Ray D. Wolfe Department of Family Medicine, Sinai Health, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nelia De Oliveira
- Ray D. Wolfe Department of Family Medicine, Sinai Health, Toronto, Ontario, Canada
| | - David Tannenbaum
- Ray D. Wolfe Department of Family Medicine, Sinai Health, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jeff Bloom
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Camille Lemieux
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Patricia Marr
- Department of Family and Community Medicine, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Michelle Levy
- Ray D. Wolfe Department of Family Medicine, Sinai Health, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mira Mitri
- Ray D. Wolfe Department of Family Medicine, Sinai Health, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sakina Walji
- Ray D. Wolfe Department of Family Medicine, Sinai Health, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sahana Kukan
- Ray D. Wolfe Department of Family Medicine, Sinai Health, Toronto, Ontario, Canada
| | - Andrew M Morris
- Antimicrobial Stewardship Program, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, Division of Infectious Diseases, Sinai Health, University Health Network, and University of Toronto, Toronto, Ontario, Canada
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7
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Vik I, Mdala I, Bollestad M, Cordoba GC, Bjerrum L, Neumark T, Damsgaard E, Bærheim A, Grude N, Lindbaek M. Predicting the use of antibiotics after initial symptomatic treatment of an uncomplicated urinary tract infection: analyses performed after a randomised controlled trial. BMJ Open 2020; 10:e035074. [PMID: 32868350 PMCID: PMC7462246 DOI: 10.1136/bmjopen-2019-035074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To predict antibiotic use after initial treatment with ibuprofen using data from a randomised controlled trial comparing ibuprofen to pivmecillinam in the treatment of women with symptoms of an uncomplicated urinary tract infection (UTI). SETTING 16 sites in a primary care setting in Norway, Sweden and Denmark. PARTICIPANTS Data from 181 non-pregnant women aged 18-60 presenting with symptoms of uncomplicated UTI, initially treated with ibuprofen. METHODS Using the least absolute shrinkage and selection operator logistic regression model, we conducted analyses to see if baseline information could help us predict which women could be treated with ibuprofen without risking treatment failure and which women should be recommended antibiotics. RESULTS Of the 143 women included in the final analysis, 77 (53.8%) recovered without antibiotics and 66 (46.2 %) were subsequently prescribed antibiotics. In the unadjusted binary logistic regression, the number of days with symptoms before inclusion (<3 days) and feeling moderately unwell or worse (≥4 on a scale of 0-6) were significant predictors for subsequent antibiotic use. In the adjusted model, no predictors were significantly associated with subsequent antibiotic use. The area under the curve of the final model was 0.66 (95% CI: 0.57 to 0.74). CONCLUSION We did not find any baseline information that significantly predicted the use of antibiotic treatment. Identifying women who need antibiotic treatment to manage their uncomplicated UTI is still challenging. Larger data sets are needed to develop models that are more accurate. TRIAL REGISTRATION NUMBER ClinicalTrials.gov (NCT01849926).
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Affiliation(s)
- Ingvild Vik
- Department of General Practice, Antibiotic Centre for Primary Care, Institute of Health and Society, University of Oslo, Oslo, Norway
- Department of Emergency General Practice, City of Oslo Health Agency, Oslo Accident and Emergency Outpatient Clinic, Oslo, Norway
| | - Ibrahimu Mdala
- General Practice Research Unit (AFE), Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Marianne Bollestad
- Department of General Practice, Antibiotic Centre for Primary Care, Institute of Health and Society, University of Oslo, Oslo, Norway
- Medicine, Helse Stavanger HF, Stavanger, Norway
| | - Gloria Cristina Cordoba
- Section of General Practice and Research Unit of General Practice, Department of Public Health, University of Copenhagen, København, Denmark
| | - Lars Bjerrum
- Section of General Practice and Research Unit of General Practice, Department of Public Health, University of Copenhagen, København, Denmark
| | - Thomas Neumark
- Primary Health Care and Planning Division, Kalmar County Council, Kalmar, Sweden
| | - Eivind Damsgaard
- Bergen Accident and Emergency Department, Bergen Kommune, Bergen, Norway
| | - Anders Bærheim
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Hordaland, Norway
| | - Nils Grude
- Department of General Practice, Antibiotic Centre for Primary Care, Institute of Health and Society, University of Oslo, Oslo, Norway
- Department of Medical Microbiology, Vestfold Hospital Trust, Tønsberg, Norway
| | - Morten Lindbaek
- Department of General Practice, Antibiotic Centre for Primary Care, Institute of Health and Society, University of Oslo, Oslo, Norway
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8
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Jeffs L, McIsaac W, Zahradnik M, Senthinathan A, Dresser L, McIntyre M, Tannenbaum D, Bell C, Morris A. Barriers and facilitators to the uptake of an antimicrobial stewardship program in primary care: A qualitative study. PLoS One 2020; 15:e0223822. [PMID: 32134929 PMCID: PMC7059986 DOI: 10.1371/journal.pone.0223822] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 09/30/2019] [Indexed: 01/21/2023] Open
Abstract
The overuse of antimicrobials in primary care can be linked to an increased risk of antimicrobial-resistant bacteria for individual patients. Although there are promising signs of the benefits associated with Antimicrobial Stewardship Programs (ASPs) in hospitals and long-term care settings, there is limited knowledge in primary care settings and how to implement ASPs in these settings is unclear. In this context, a qualitative study was undertaken to explore the perceptions of primary care prescribers of the usefulness, feasibility, and experiences associated with the implementation of a pilot community-focused ASP intervention in three primary care clinics. Qualitative interviews were conducted with primary care clinicians, including local ASP champions, prescribers, and other primary health care team members, while they participated in an ASP initiative within one of three primary care clinics. An iterative conventional content analyses approach was used to analyze the transcribed interviews. Themes emerged around the key enablers and barriers associated with ASP implementation. Study findings point to key insights relevant to the scalability of community ASP activities with primary care providers.
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Affiliation(s)
- Lianne Jeffs
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto,
Ontario, Canada
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michaels
Hospital, Toronto, Ontario, Canada
| | - Warren McIsaac
- Ray D. Wolfe Department of Family and Community Medicine, Sinai Health
System, Toronto Canada
- Department of Family and Community Medicine, University of Toronto,
Toronto, Canada
| | | | - Arrani Senthinathan
- Antimicrobial Stewardship Program, Sinai Health System and University
Health Network, Toronto, Canada
| | - Linda Dresser
- Antimicrobial Stewardship Program, Sinai Health System and University
Health Network, Toronto, Canada
| | - Mark McIntyre
- Antimicrobial Stewardship Program, Sinai Health System and University
Health Network, Toronto, Canada
| | - David Tannenbaum
- Ray D. Wolfe Department of Family and Community Medicine, Sinai Health
System, Toronto Canada
- Department of Family and Community Medicine, University of Toronto,
Toronto, Canada
| | - Chaim Bell
- Antimicrobial Stewardship Program, Sinai Health System and University
Health Network, Toronto, Canada
- Department of Medicine, Sinai Health System, University Health Network,
and University of Toronto, Toronto, Canada
| | - Andrew Morris
- Antimicrobial Stewardship Program, Sinai Health System and University
Health Network, Toronto, Canada
- Department of Medicine, Sinai Health System, University Health Network,
and University of Toronto, Toronto, Canada
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9
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Caskurlu H, Culpan M, Erol B, Turan T, Vahaboglu H, Caskurlu T. Changes in Antimicrobial Resistance of Urinary Tract Infections in Adult Patients over a 5-Year Period. Urol Int 2020; 104:287-292. [PMID: 31940639 DOI: 10.1159/000504415] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 10/29/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVES We aimed to determine the most common bacteria that cause urinary tract infections (UTIs), the rate of antibiotic resistance of these uropathogens, and the changes in resistance rates over the years for adult patients diagnosed with UTIs. METHODS We retrospectively reviewed urine cultures and antibiotic susceptibility results of patients >17 years of age from our outpatient clinic between 2014 and 2018. The most common uropathogens and their antibiotic resistance rates were identified in different age groups (18-39, 40-59, and ≥60 years) and with respect to gender and date of admission. In addition, the change in antibiotic resistance of Escherichia coli between 2014 and 2018 was also examined. RESULTS A total of 9,556 positive urine cultures were included. The most common uropathogen was E. coli, and its prevalence was higher in females than males (70.6 vs. 53.4%, respectively). The majority of isolates were from patients ≥60 years of age. E. coli resistance was most pronounced for ampicillin (61.56%), followed by trimeth-oprim-sulfamethoxazole (49.80%), amoxicillin-clavulanic acid (34.69%), and cefazolin (30.72%). E. coli resistance to ampicillin, nitrofurantoin, cefepime, ciprofloxacin, fosfomycin, and amoxicillin-clavulanic acid increased significantly with time (all p = 0.001). For E. coli, resistance to ciprofloxacin, one of the most commonly used antibiotics for UTI, increased from 17 to 43% from 2014 to 2018. CONCLUSION Most of the uropathogens displayed high resistance to ampicillin, tri-methoprim-sulfamethoxazole, and amoxicillin-clavulanic acid, and were susceptible to meropenem, ertapenem, and imipenem. Fosfomycin and cefepime were useful in the empirical treatment of community-acquired UTIs. A surprisingly high increase was observed in the resistance of E. coli to antimicrobial agents from 2014 to 2018.
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Affiliation(s)
- Hulya Caskurlu
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Meftun Culpan
- Department of Urology, Faculty of Medicine, Istanbul Okan University, Istanbul, Turkey
| | - Bulent Erol
- Department of Urology, Goztepe Training and Research Hospital, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey,
| | - Turgay Turan
- Department of Urology, Turgutlu State Hospital, Manisa, Turkey
| | - Haluk Vahaboglu
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Turhan Caskurlu
- Department of Urology, Goztepe Training and Research Hospital, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
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Bunce JT, Hellyer P. Antibiotic resistance and antibiotic prescribing by dentists in England 2007-2016. Br Dent J 2019; 225:81-84. [PMID: 30002521 DOI: 10.1038/sj.bdj.2018.525] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2018] [Indexed: 11/09/2022]
Abstract
The early prescribers of penicillin realised that antibiotics should be used wisely and as an adjunct to traditional surgical provision. They predicted that inappropriate use would increase sensitisation to the drug. National Health Service dentists prescribed almost 10% of antibiotics issued in NHS general practice in 2016 and an audit shows that many of these may have been prescribed inappropriately. One of the causes of antimicrobial resistance is over prescription of the drugs. This paper recalls the recommendations of some early users of penicillin, reports on the current prescription patterns of dentists in England, describes the mechanism of acquisition of anti-microbial resistance and discusses dentists' role in attempting to reduce the problem.
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Affiliation(s)
- J T Bunce
- School of Engineering, Newcastle University, Newcastleupon-Tyne, NE1 7RU
| | - P Hellyer
- University of Portsmouth Dental Academy, Hampshire Terrace, Portsmouth, PO1 2QG
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11
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Pre-test probability of urinary tract infection in dogs with clinical signs of lower urinary tract disease. Vet J 2019; 247:65-70. [PMID: 30971354 DOI: 10.1016/j.tvjl.2019.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 01/22/2019] [Accepted: 03/13/2019] [Indexed: 11/20/2022]
Abstract
Clinical signs of lower urinary tract disease in dogs are characteristic but non-specific for infection. It has been hypothesized that age, sex and neuter status influences the prevalence of urinary tract infection (UTI), but the predictive value of the combined clinical presentation has not been explored in dogs. The aim of the study was to assess clinical predictors (sex/neuter status, age, dysuria/stranguria, pollakiuria, macroscopic hematuria, malodorous urine and history of recurrent UTI) for bacterial cystitis, and to develop a clinical decision rule. Data was retrieved from medical records (retrospective cases) or from standardized recording sheets (prospective cases). Bacterial cystitis was defined as significant bacteriuria on quantitative bacterial culture in dogs with compatible clinical signs of urinary tract disease. Dogs of any breed, sex and age were included. A total of 1727 microbiology records were screened and 424 samples were included in the analysis. Bacterial cystitis was confirmed in 46% of the cases. Four variables predicted bacterial cystitis: sex/neuter status, age, pollakiuria and hematuria. A score was designated to each variable and a clinical rule was constructed. This rule attained an AUC of 0.75 and had sensitivity of 83% and specificity of 55% at its optimal cut-off (score ≥2.0). A score cut-off of ≥3.0 had a positive predictive value of 70%. Several factors predicted bacterial cystitis, but the clinical rule had only modest predictive value. Other variables or point-of-care test results should be included in future research to optimize overall precision.
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12
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Bauer DW, Adkison J, Hamilton H. Knowledge and Practice Discordance in Treating Urinary Tract Infections. PRIMER (LEAWOOD, KAN.) 2018; 2:26. [PMID: 32818198 PMCID: PMC7426118 DOI: 10.22454/primer.2018.742456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND AND OBJECTIVES Urinary tract infections (UTIs) are a common condition in women. Guidelines have been published on the diagnosis and management of such infections with the twin goals of improved patient safety and avoiding unnecessary health care costs. In this study we evaluated both physicians' knowledge of these guidelines, and whether that knowledge translates to their clinical practice. METHODS We performed a retrospective chart review of UTI management before and after an educational intervention in a family medicine residency. Two control sites were also included. We also assessed physicians' knowledge of current UTI management guidelines using an anonymous quiz. RESULTS At the intervention site, guideline adherence improved following the educational session. Inappropriate culture use decreased from 88% to 68% (P<.005) while first-line antibiotic use increased from 68% to 92% (P<.005). No such benefits were seen at the control sites. The control and intervention site providers did not differ in knowledge of antibiotic choice on the quiz (86% and 88% correct respectively, P=.85), but all control providers felt routine cultures were appropriate, whereas only 38% of the intervention providers did (P<.05). CONCLUSIONS A simple educational intervention made an impact on the management of UTI. Our results also highlighted that knowledge and practice are not always aligned.
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Affiliation(s)
- David W Bauer
- Memorial Family Medicine Residency Program, Sugar Land, TX
| | - Julie Adkison
- Memorial Family Medicine Residency Program, Sugar Land, TX
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