Consultations and antibiotic treatment for urinary tract infections in Norwegian primary care 2006-2015, a registry-based study

Treatment Related to Urinary Tract Infections Is Associated with Delayed Diagnosis of Urinary Bladder Cancer: A Nationwide Population-based Study

BACKGROUND AND OBJECTIVE

It has been suggested that urinary tract infections (UTIs) are associated with delayed diagnosis of bladder cancer (BC). Our aim was to investigate prediagnostic treatments related to UTI and the relation to BC diagnostic delay, reflected by advanced disease at diagnosis.

METHODS

We used data from the BladderBaSe 2.0 with data of treatments related to UTI up to 3 yr before BC diagnosis (2008-2019) for BC patients in comparison to a matched reference population. We investigated the association between UTI treatments and more advanced disease at diagnosis in the BC cohort. We used generalized ordered logistic regression to calculate odds ratios (ORs) for more advanced disease as an ordered outcome: non-muscle-invasive BC (NMIBC), muscle-invasive BC (MIBC), and metastatic BC (MBC).

KEY FINDINGS AND LIMITATIONS

The study population included 29 921 BC patients and 149 467 matched reference subjects. The proportions of individuals receiving UTI treatment were higher in the patient groups than in the corresponding reference groups, with the greatest differences observed for the MIBC and MBC subgroups. The OR for the risk of more advanced disease (MIBC or MBC) with at least one UTI treatment versus none was 1.28 (95% confidence interval [CI] 1.19-1.37) for men and 1.42 (95 % CI 1.27-1.58) for women. The association to risk of more advanced disease increased with the number of UTI treatments for both sexes.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Further studies on the effects of treatments related to UTI in combination with other factors are needed to identify reasons for possible delays in the BC diagnostic pathway.

PATIENT SUMMARY

We found that for patients with bladder cancer, previous antibiotic treatment for a urinary tract infection was linked to more advanced disease at diagnosis. Further studies are needed to identify reasons for possible delays in the diagnosis of bladder cancer.

Acute cystitis in men- a nationwide study from primary care: antibiotic prescriptions, risk factors, and complications

BACKGROUND

Research on acute cystitis in men is scarce and treatment guidelines differ between countries. Improved antibiotic stewardship is needed.

AIM

To analyse antibiotic prescriptions and outcomes of Norwegian men diagnosed with cystitis in primary care.

DESIGN & SETTING

A nationwide retrospective study was undertaken in primary care in Norway.

METHOD

We identified all episodes of acute cystitis in men diagnosed in Norwegian primary care during 2012-2019. Choice of antibiotic (from the Norwegian Prescription Database), treatment failure, re-prescription, and complications were stratified by age, calendar year, and risk factors. We used logistic regression to explore predefined risk factors (diabetes, prostate cancer, benign prostate hyperplasia [BPH], urinary retention, and any cancer) with complications (pyelonephritis, prostatitis, and hospitalisation) and re-prescriptions. Linear regression was used to explore time trends.

RESULTS

In total, 108 994 individuals contributed 148 635 episodes. Narrow-spectrum antibiotics were first-choice treatment in 71.0% of the episodes (52.5% of all prescriptions were pivmecillinam). More than 75% of the episodes with narrow-spectrum versus 82.2% of broad-spectrum treatment did not lead to any re-prescription or complication. Complications occurred in 1.8% of all episodes (0.5% prostatitis, 0.7% pyelonephritis, and 0.7% hospitalisation). BPH was associated with increased risk of complications and re-prescription. Diabetes was associated with a lower risk of re-prescriptions. Prostate cancer and urinary retention were associated with a lower risk of both complications and re-prescriptions.

CONCLUSION

Our results support narrow-spectrum antibiotics as first-line treatment. Risk factor analyses warrants further investigation.

Effect of methenamine hippurate shortage on antibiotic prescribing for urinary tract infections in Norway-an interrupted time series analysis

BACKGROUND

Despite a lack of conclusive evidence of effect, methenamine hippurate is widely prescribed as preventive treatment for recurrent urinary tract infections (UTIs) in Norway. A national discontinuation of methenamine hippurate treatment due to a 4-month drug shortage in 2019 presented an opportunity to evaluate its preventive effect on UTIs among regular users.

OBJECTIVE

To estimate the impact of the methenamine hippurate drug shortage on prescription frequency of UTI antibiotics.

METHODS

Data from The Norwegian Prescription Database was analysed using an interrupted time series design. The time series consisted of 56 time periods of 14 days. The model included two naturally occurring interruptions: (i) the methenamine hippurate drug shortage, and (ii) reintroduction of the drug. The study population were 18 345 women ≥50 years receiving ≥2 prescriptions of methenamine hippurate in the study period before the shortage. Main outcome measure was number of prescriptions of UTI antibiotics per 1000 methenamine hippurate users. Prescription rates of antibiotics for respiratory tract infections were analysed to assess external events affecting antibiotic prescribing patterns.

RESULTS

We found a significant increase of 2.41 prescriptions per 1000 methenamine hippurate users per 14-day period during the drug shortage (95%CI 1.39, 3.43, P < 0.001), followed by a significant reduction of -2.64 prescriptions after reintroduction (95%CI -3.66, -1.63, P < 0.001).

CONCLUSIONS

During the methenamine hippurate drug shortage, we found a significant increase in prescribing trend for UTI antibiotics followed by a significant decrease in prescribing trend after reintroduction. This change in trend seems to reflect a preventive effect of the drug on recurrent UTIs.

Transcriptomic profiles of brains in juvenile Atlantic cod (Gadus morhua) exposed to pharmaceuticals and personal care products from a wastewater treatment plant discharge

Pharmaceuticals and personal care products (PPCPs) are frequently detected in marine environments, posing a threat to aquatic organisms. Our previous research demonstrated the occurrence of neuroactive compounds in effluent and sediments from a wastewater treatment plant (WWTP) in a fjord North of Stavanger, the fourth-largest city in Norway. To better understand the influence of PPCP mixtures on fish, Atlantic cod (Gadus morhua) were caged for one month in 3 locations: site 1 (reference), site 2 (WWTP discharge), and site 3 (6.7 km west of discharge). Transcriptomic profiling was conducted in the brains of exposed fish and detection of PPCPs in WWTP effluent and muscle fillets were determined. Caffeine (47.8 ng/L), benzotriazole (10.9 ng/L), N,N-diethyl-meta-toluamide (DEET) (5.6 ng/L), methyl-1H-benzotriazole (5.5 ng/L), trimethoprim (3.4 ng/L), carbamazepine (2.1 ng/L), and nortriptyline (0.4 ng/L) were detected in the WWTP effluent. Octocrylene concentrations were observed in muscle tissue at all sites and ranged from 53 to 193 ng/g. Nervous system function and endocrine system disorders were the top enriched disease and function pathways predicted in male and female fish at site 2, with the top shared canonical pathways involved with estrogen receptor and Sirtuin signaling. At the discharge site, predicted disease and functional responses in female brains were involved in cellular assembly, organization, and function, tissue development, and nervous system development, whereas male brains were involved in connective tissue development, function, and disorders, nervous system development and function, and neurological disease. The top shared canonical pathways in females and males were involved in fatty acid activation and tight junction signaling. This study suggests that pseudopersistent, chronic exposure of native juvenile Atlantic cod from this ecosystem to PPCPs may alter neuroendocrine and neuron development.

In vitro susceptibility to fosfomycin in clinical and environmental extended-spectrum beta-lactamase producing and/or ciprofloxacin-non-susceptible Escherichia coli isolates

Extended-spectrum beta-lactamase producing and ciprofloxacin-non-susceptible Escherichia coli are clinical and environmental issues. We evaluated the susceptibility profile of fosfomycin in non-susceptible E. coli isolated from urine and the environment. We measured the activity of fosfomycin against 319 and 36 E. coli strains from urine and environmental isolates, respectively, collected from rivers. Fosfomycin resistance profiles were investigated using the minimal inhibitory concentration (MIC), according to the Clinical and Laboratory Standards Institute (CLSI) and the European Committee for Antimicrobial Susceptibility Testing (EUCAST) guidelines. Antibiotic susceptibility testing revealed that 5% and 6.6% of urine samples were non-susceptible to fosfomycin according to CLSI and EUCAST guidelines, respectively. The fosfomycin MIC50/90 was 0.5/4 mg/L. Of the 36 E. coli isolates from river water, 11.1% and 13,8% were non-susceptible to fosfomycin according to CLSI and EUCAST, respectively (range ≤0.25 ≥512 mg/L). All the isolates with MIC ≥512 mg/L for fosfomycin showed the fosA3 gene. Fosfomycin resistance was more frequent in the environment than in clinical samples.

Urinary Tract Infections in Men in Primary Care in Catalonia, Spain

Antimicrobial resistance is a major global problem that is primarily driven by the excessive and inappropriate utilization of antibiotics. Urinary tract infections (UTIs) are frequent in primary health care (PHC) and are typically treated with antibiotics. There is ample evidence on the management of this condition in women but not in men. The aim of this study was to describe the epidemiology of UTIs in men in Catalonia, Spain. We conducted a population-based observational cohort study that included male patients diagnosed with UTI within our SIDIAP and CMBD database during the period from 2012 to 2021. UTI diagnoses were grouped into five main groups (cystitis, prostatitis, orchitis and epididymitis, urethritis, and pyelonephritis). Of the 316,762 men with at least one recorded UTI episode, the majority were registered with a diagnosis of cystitis in PHC (212,958 patients). Quinolones were the most commonly recorded treatment for UTIs (between 18.3% and 38.6%, depending on the group), except for urethritis in which a combination of antibiotics (36.7%) was most frequently used. The treatment duration period was between 9 days and 18 days, except for the prostatitis group, in which treatment was extended to 21 days. Urine cultures were documented in up to 30% in the cystitis group. Pyelonephritis was the category linked to most septicemia cases (3.0%). Conclusions: This is the first study to assess UTIs in men using a large PHC database in Spain. The sociodemographic characteristics of our sample are similar to other studies in the literature. In our setting, the use of quinolones for the treatment of UTIs is the most registered, and its duration was between 9 days and 18 days, despite the fact that resistance to quinolones exceeds 20% of the strains in our area.

Increased demand of urine cultures from Danish general practice: a five-year register-based study

OBJECTIVE

To characterise and explore the development in the number and content of urine samples sent from general practice in the North Denmark Region to the Department of Clinical Microbiology (DCM) at Aalborg University Hospital during a five-year period.

DESIGN

A register-based study.

SETTING

General practice.

SUBJECTS

Urine samples received at DCM, Aalborg University Hospital from general practice between 2017 and 2022.

MAIN OUTCOME MEASURES

Number and content of urine samples.

RESULTS

A total of 255,271 urine samples from general practice were received at DCM, with 76.1% being from female patients. Uropathogens were identified in 43.0% of the samples. During the five-year period, a 23.0% increase in the number of urine samples per person (incidence rate ratio (IRR) 1.23, 95% CI 1.21-1.25) was observed. A slight increase in the proportion of positive cultures (risk ratio (RR) 1.03, 95% CI 1.01-1.05) was seen. No notable change in the patient population (age, gender) was observed. Overall, Escherichia coli was the most identified uropathogen (60.4%) followed by Klebsiella spp. (8.7%) and Enterococcus spp. (7.7%). Distribution of the various uropathogens differed slightly depending on patient gender and age, importantly E. coli was less frequently observed in males aged >65 years.

CONCLUSION

During the past five years an increasing amount of urine cultures have been requested at DCM from general practice. Importantly, the cause(s) of this increasing demand needs to be explored further in future studies.

Guidelines for the management of male urinary tract infections in primary care: a lack of international consensus-a systematic review of the literature

BACKGROUND

The management of adult male urinary tract infections (mUTIs) in primary care lacks international consensus. The main objective of this study was to describe the different guidelines for the diagnosis and management of mUTIs in primary care, to assess their methodological quality, and to describe their evidence-based strength of recommendation (SoR).

METHODS

An international systematic literature review of the electronic databases Medline (PubMed) and EMBASE, and gray-literature guideline-focused databases was performed in 2021. The Appraisal of Guidelines for Research and Evaluation (AGREE II) assessment tool was used by 2 independent reviewers to appraise each guideline.

RESULTS

From 1,678 records identified, 1,558 were screened, 134 assessed for eligibility, and 29 updated guidelines met the inclusion criteria (13 from Medline, 0 from EMBASE, and 16 from gray literature). Quality assessment revealed 14 (48%) guidelines with high-quality methodology. A grading system methodology was used in 18 (62%) guidelines. Different classifications of mUTIs are described, underlining a lack of international consensus: an anatomic classification (cystitis, prostatitis, pyelonephritis) and a symptomatic classification (approach based on the intensity and tolerance of symptoms). The duration of antibiotic treatment for febrile mUTIs has been gradually reduced over the last 20 years from 28 days to 10-14 days of fluoroquinolones (FQ), which has become the international gold standard. Guidelines from Scandinavian countries propose short courses (3-5 days) of FQ-sparing treatments: pivmecillinam, nitrofurantoin, or trimethoprim. Guidelines from French-speaking countries use a watchful waiting approach and suggest treating mUTIs with FQ, regardless of fever.

CONCLUSIONS

This lack of scientific evidence leads to consensus and disagreement: 14 days of FQ for febrile mUTIs is accepted despite a high risk of antimicrobial resistance, but FQ-sparing treatment and/or short treatment for afebrile mUTIs is not. The definition of afebrile UTIs/cystitis is debated and influences the type and duration of antibiotic treatment recommended.

Improved management of cystitis in primary care following the implementation of a simple multifaceted intervention

OBJECTIVE

We assessed the impact of the implementation of a simple multifaceted intervention aimed at improving management of cystitis in primary care.

DESIGN

Quality control before and after study. SITE: Primary care centres in Barcelona city provided by the Catalonian Institute of Health.

PARTICIPANTS

The multifaceted intervention consisted of (1) creation of a group with a leader in each of the primary care centres, out of hours services, sexual and reproductive centres, and home visit service, (2) session on management of cystitis in each centre, (3) result feedback for professionals, and (4) provision of infographics for professionals and patients with urinary tract infections. Interventions started in November 2020 and ended in the summer of 2021.

MAIN MEASUREMENTS

Variation in the prescription of first-line antibiotics, usage of antibiotics, and request for urine cultures before and after this intervention.

RESULTS

Training sessions took place in 93% of the centres. The use of first-line therapies cystitis increased by 6.4% after the intervention (95% confidence interval [CI], 5.7-7.1%). The use of nitrofurantoin in recurrent cystitis increased, mainly in out of hours service (8.7%; 95% CI, 5.2-12.2%). Urine cultures were more frequently requested after the intervention for recurrent cystitis in both primary care centres and out of hours services, with a 7.2% increase [95% CI, 5.9-8.5%), but also for uncomplicated urinary tract infections (3.1%; 95% CI, 1.8-4.4%).

CONCLUSIONS

A low-intensity multifaceted intervention on management of cystitis, with strong institutional support, resulted in a better choice of antibiotic in antibiotic prescribing, but the intervention had less impact on the adequacy of urine cultures.

Preventive effect of methenamine in women with recurrent urinary tract infections - a case-control study

BACKGROUND

Urinary tract infection (UTI) is the most common bacterial infection in women. In Norwegian general practice, methenamine has been prescribed for many years as long-term prevention and accounted for 20% of the total antibiotic prescribing in 2015, as measured in defined daily dosages (DDDs). The efficacy of methenamine is unknown. If shown to be effective, this drug may become an important preventive against UTI.

OBJECTIVE

To examine whether methenamine is preventive against recurrent UTI in women.

DESIGN

Data for all antibiotics used for UTIs dispensed from all pharmacies from 2005 to 2015 were collected from the Norwegian prescription database (NorPD).

SUBJECTS

Women aged ≥ 40 years with recurrent UTI, defined as ≥3 courses of UTI antibiotic/year, were included.

MAIN OUTCOME MEASURES

Patients using methenamine (cases) and those not using methenamine (controls) were compared. The numbers of UTI prescriptions during the 2 years before and after inclusion were analysed. Results: The yearly prevalence for recurrent UTI was 2.4% in women ≥ 40 years. The change in antibiotic use from 2 years before to 2 years after inclusion in the study differed significantly between groups: 44.6 and 34.9% reductions in the number of antibiotic prescriptions for UTI in the methenamine and control groups, respectively. The decrease in UTI antibiotic prescriptions (58.9%) was greater in patients with a higher consumption of antibiotics before starting methenamine.

CONCLUSIONS

Methenamine seems to be effective against recurrent UTI over the time span studied. The effect seems to be greater in patients with the highest number of recurrent UTIs. Key pointsMethenamine has been used for many years for prevention of recurrent UTI, but no studies have demonstrated a significant preventive effect of long time use.This study shows that methenamine seems to be effective for prevention in patients having recurrent UTI over 2 years or more.The effect seems to be larger in patients with a high number of UTIs over 2 years.

Patterns and trends of antibacterial treatment in patients with urinary tract infections, 2015–2019: an analysis of health insurance data

Background

Urinary tract infections are among the most common reason for encounter and subsequent antibiotic prescriptions. Due to the risk of collateral damage and increasing resistance rates, explicit recommendations against the use of fluoroquinolones like ciprofloxacin in uncomplicated urinary tract infections have been issued. However, to what extent these recommendations were followed and if there are relevant differences between the disciplines involved (general practitioners, urologists, paediatricians and gynaecologists) are unknown.

Methods

We used anonymized data from a local statutory health insurance (SHI) company, which covered about 38% of all SHI-insured persons in the federal state of Bremen, Germany between 2015—2019. Data included demographics, outpatient diagnoses and filled prescriptions on an individual level.

Results

One-year prevalence of urinary tract infections was 5.8% in 2015 (females: 9.2%, males: 2.5%). Of all 102,715 UTI cases, 78.6% referred to females and 21.4% to males, 6.0% of cases were younger than 18 years. In females, general practitioners were the most common diagnosing speciality (52.2%), followed by urologists (20.0%) and gynaecologists (16.1%). Overall, fluoroquinolones were most often prescribed (26.3%), followed by fosfomycin (16.1%) and the combination of sulfamethoxazole and trimethoprim (14.2%). Fluoroquinolones were most often prescribed by urologists and general practitioners, while gynaecologists preferred fosfomycin. During the study period, shares of fluoroquinolones decreased from 29.4% to 8.7% in females and from 45.9% to 22.3% in males.

Conclusions

Despite a clear trend toward a more guideline adherent prescription pattern, there is still room for improvement regarding the use of second-line antibiotics especially fluoroquinolones. The choice of antibiotics prescribed differs between specialities with higher uptake of guideline-recommended antibiotics by gynaecologists, mainly because of higher prescription shares of fosfomycin.

Identifying women's preferences for treatment of urinary tract infection: a discrete choice experiment

OBJECTIVE

To identify the preferences of women regarding management of urinary tract infections (UTIs).

DESIGN

A discrete choice experiment of the preferences for certain treatment attributes was conducted by survey. Attributes included treatment duration, time to complaint resolution, complication risk, side effect risk and contribution to antimicrobial resistance.

SETTING

General population in the Netherlands, recruited via social media.

PARTICIPANTS

Women aged 18 years or older.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the relative importance of the attributes for treatment choice, using a conditional logit model. The secondary outcome was the heterogeneity in these preferences.

RESULTS

The discrete choice experiment was completed by 833 women. Most attributes were important to decisions for UTI treatment. Women were willing to accept management with, for example, a higher chance of complications or longer time to resolution, if it could help avoid antimicrobial resistance. However, there was heterogeneity in the preferences. Women who had one previous UTI had a stronger preference for faster symptom resolution compared with those who had no previous UTI. Younger women also preferred faster symptom resolution. Finally, women with a low or middle education level gave less importance to preventing antimicrobial resistance than women with a high education level.

CONCLUSIONS

The current study indicated that a considerable part of women valued alternatives to antimicrobial treatment and were prepared to tolerate management that was less optimal in certain respects to avoid antimicrobial treatment.