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Kurotschka PK, Hemkeppler J, Gierszewski D, Ghirotto L, Gágyor I. General practitioners' decision making managing uncomplicated urinary tract infections in women: a qualitative study. BJGP Open 2024:BJGPO.2023.0224. [PMID: 38423622 DOI: 10.3399/bjgpo.2023.0224] [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: 11/06/2023] [Revised: 01/03/2024] [Accepted: 02/07/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND To be effective, interventions aimed at increasing the appropriateness of antibiotic use in primary care should consider the perspectives of prescribing physicians. AIM To explore the decision making of general practitioners (GPs) when managing uncomplicated urinary tract infections (uUTIs) in women. DESIGN & SETTING A qualitative study using semi-structured interviews with 22 GPs in Bavaria and Baden-Württemberg (southern Germany). METHOD Verbatim transcripts were analysed through inductive qualitative content analysis. RESULTS We generated the following three main themes: factors facilitating the decision making; factors complicating the decision making; and consultation modalities. According to participants, following evidence-based recommendations makes the prescription decision smoother. GPs' and patients' prior experiences and beliefs guides decisions towards certain antibiotics, even if those experiences and beliefs contradict evidence-based recommendations. Patient expectations and demands also condition antibiotic prescribing, favouring it. Organisational constraints, such as time pressure, the day of the week (for example, before weekends), and a lower cost of antibiotics for patients than alternative treatments favour the decision to prescribe antibiotics. Diagnostic and prognostic uncertainty complicates decision making, as does scepticism towards evidence-based recommendations. Discordance within the patient-doctor relationship contributed to this complexity. Regarding consultation modalities, a more in-depth consultation and shared decision making were seen as helpful in this process. CONCLUSION We identified different factors as intervening against or for a straightforward management decision when dealing with women with uUTIs. They reveal the complexity behind the GPs' decision making. Providing GPs with easy-to-apply guidance while removing economic constraints to allocate sufficient consultation time, and supporting shared decision making may help GPs appropriately manage uUTIs in women.
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Affiliation(s)
- Peter K Kurotschka
- Department of General Practice, University Hospital Wurzburg, Wurzburg, Germany
| | - Juliane Hemkeppler
- Department of General Practice, University Hospital Wurzburg, Wurzburg, Germany
| | - David Gierszewski
- Department of General Practice, University Hospital Wurzburg, Wurzburg, Germany
| | - Luca Ghirotto
- Qualitative Research Unit, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Ildikó Gágyor
- Department of General Practice, University Hospital Wurzburg, Wurzburg, Germany
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Park J, Torosis M, Kim JH, Ackerman AL. U.S. primary care physician perceptions on barriers to providing guideline-driven care for UTI and recurrent UTI: a qualitative study. BMC PRIMARY CARE 2024; 25:234. [PMID: 38951826 PMCID: PMC11218267 DOI: 10.1186/s12875-024-02477-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 06/11/2024] [Indexed: 07/03/2024]
Abstract
BACKGROUND Urinary tract infections (UTI) affect almost two-thirds of all women during their lives and many experience recurrent infections. There are evidence-based guidelines from multiple international societies for evaluation and treatment; however, recent claims-based analyses have demonstrated that adherence to these guidelines is poor. This study seeks to understand the barriers experienced by U.S. primary care providers (PCPs) to providing guideline-based care for UTI and recurrent UTI (rUTI). METHODS Semi-structured interviews of 18 PCPs, recruited from the greater Los Angeles area, examined real-world clinical management of UTI/rUTI episodes, decisions to refer to subspecialty care, and resources guiding counseling and management. Grounded theory methodology served to analyze interview transcripts and identify preliminary and major themes. RESULTS Participants expressed the desire to obtain urine cultures for each cystitis episode, but felt pressured to make compromises by patient demands or barriers to care. PCPs had lower thresholds to empirical treatment if patients had a history of rUTIs, were elderly, or declined evaluation. Laboratory data was minimally utilized in clinical decision-making: urinalyses were infrequently considered when interpreting culture data. PCPs treated a broad set of urologic and non-urologic symptoms as UTI, even with negative cultures. PCPs did not feel comfortable initiating UTI prophylaxis, instead seeking specialist evaluation for anatomic causes. They were unaware of management guidelines, typically utilizing UpToDate® as their primary resource. Few evidence-based UTI prevention interventions were recommended by providers. CONCLUSIONS Low availability of succinct and clear professional guidelines are substantial barriers to appropriate UTI/rUTI care. Poor useability of clinical guidance documents results in substantial confusion about the role of preventative measures and additional diagnostic testing. Difficulties in patient access to care providers lead to expectations for presumptive treatment. Future studies are needed to determine if improved educational materials for providers and/or management algorithms can improve guideline concordance of UTI management.
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Affiliation(s)
- Jennifer Park
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Box 951738, Los Angeles, CA, 90095-1738, USA
| | - Michele Torosis
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Box 951738, Los Angeles, CA, 90095-1738, USA
| | - Ja-Hong Kim
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Box 951738, Los Angeles, CA, 90095-1738, USA
- Department of Urology, Division of Pelvic Medicine and Reconstructive Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, 90095, USA
| | - A Lenore Ackerman
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Box 951738, Los Angeles, CA, 90095-1738, USA.
- Department of Urology, Division of Pelvic Medicine and Reconstructive Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, 90095, USA.
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Krinner A, Schultze M, Marijam A, Pignot M, Kossack N, Mitrani-Gold FS, Joshi AV. Treatment Patterns and Adherence to Guidelines for Uncomplicated Urinary Tract Infection in Germany: A Retrospective Cohort Study. Infect Dis Ther 2024; 13:1487-1500. [PMID: 38869841 PMCID: PMC11219654 DOI: 10.1007/s40121-024-00973-8] [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: 12/11/2023] [Accepted: 04/04/2024] [Indexed: 06/14/2024] Open
Abstract
INTRODUCTION Understanding antibiotic prescribing for uncomplicated urinary tract infection (uUTI) could help to optimize management. However, data on uUTI treatment patterns in the European Union are scarce. We used real-world data to evaluate adherence to antibiotic prescribing guidelines for femalepatients with uUTI in Germany. METHODS This retrospective cohort study used anonymized German statutory health insurance claims data from the Wissenschaftliches Institut für Gesundheitsökonomie und Gesundheitssystemforschung from January 2013 to December 2019. Patients were female, aged ≥ 12 years, with an index uUTI diagnosis. Patient characteristics and treating physician specialties were examined overall and in sub-cohorts for recommended/non-recommended treatment (based on initial therapy adherence to German uUTI treatment guidelines) and optimal/sub-optimal outcome (based on a prescription of different antibiotics or a urinary tract infection-related episode). RESULTS Overall, 144,645 uUTI cases in 124,971 patients were analyzed; 51,230 (35.4%) and 93,415 (64.6%) cases were assigned to the recommended/non-recommended treatment sub-cohorts, respectively. Clinically meaningful differences in age and comorbidities were observed between these sub-cohorts. Most cases had an optimal outcome (n = 122,823; 84.9%); of these, a higher proportion received antibiotics that were recommended but not as first-choice versus first-choice therapies as their initial treatment (58.6% vs. 35.3%). In the sub-optimal outcome cohort, 49.1% received antibiotics that were recommended but not as first-choice and 41.1% received first-choice therapies as their initial treatment. Most uUTIs were treated by general practitioners (GPs; 82.3%), followed by gynecologists (13.3%), and urologists (6.8%). Notably, 64.5% of initial therapy prescriptions filled by gynecologists and 32.1% by GPs were first-choice antibiotics. CONCLUSION A high proportion of prescribed treatments for the initial uUTI episode were not recommended by German uUTI guidelines as first-choice antibiotics. Prescribing adherence varied by physician specialty; specialists showed greater adherence to treatment guidelines versus GPs. This study provides a novel and multi-dimensional picture of uUTI treatment in Germany.
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Affiliation(s)
- Axel Krinner
- WIG2 GmbH Scientific Institute for Health Economics and Health System Research, Leipzig, Germany
| | - Michael Schultze
- ZEG - Berlin Center for Epidemiology and Health Research GmbH, Berlin, Germany
| | - Alen Marijam
- GSK, 1250 S Collegeville Rd, Collegeville, PA, 19426, US
| | - Marc Pignot
- ZEG - Berlin Center for Epidemiology and Health Research GmbH, Berlin, Germany
| | - Nils Kossack
- WIG2 GmbH Scientific Institute for Health Economics and Health System Research, Leipzig, Germany
| | | | - Ashish V Joshi
- GSK, 1250 S Collegeville Rd, Collegeville, PA, 19426, US.
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Acampora M, Paleologo M, Graffigna G, Barello S. Uncovering influential factors in human antibiotic prescribing: a meta-synthesis study informed by the Theoretical Domains Framework. J Hosp Infect 2024; 144:28-55. [PMID: 38092303 DOI: 10.1016/j.jhin.2023.11.017] [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: 07/06/2023] [Revised: 09/28/2023] [Accepted: 11/30/2023] [Indexed: 01/05/2024]
Abstract
This study aimed to identify modifiable determinants (facilitators and barriers) related to the choice of prescribing antibiotics in human medicine across clinical settings. Enhanced management of antibiotics can help slow the spread of resistant bacteria. A qualitative meta-synthesis approach was used, according to Sandelowski and Barroso's method. Included studies were evaluated using the Critical Appraisal Skills Programme. Findings were extracted and organized to form a qualitative meta-summary. The Theoretical Domains Framework, the Capabilities-Opportunities-Motivation (COM-B) model and the Behaviour Change Wheel were used as a coding matrix for data interpretation. The analysis of 63 included studies revealed barriers and facilitators in 12 of 14 domains specified by the Theoretical Domains Framework. Prescribers' capabilities, motivation and opportunities were found to be the main drivers of antibiotic prescribing behaviour. Knowledge, skills, beliefs, expectations, the influence of patients and colleagues, organizational culture and infrastructure characteristics have a significant impact on prescribing behaviours. A comprehensive inventory of factors related to antibiotic prescribing has been compiled. Interventions to promote appropriate antibiotic prescribing should take a systemic approach rather than focusing solely on individual-level variables. Furthermore, the adoption of co-design approaches for such interventions is desirable to ensure greater applicability and sustainability in the real-world context of organizations.
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Affiliation(s)
- M Acampora
- EngageMinds HUB - Consumer, Food & Health Engagement Research Center, Università Cattolica del Sacro Cuore di Milano e Cremona, Milan and Cremona, Italy; Department of Psychology, Università Cattolica del Sacro Cuore di Milano, Milan, Italy
| | - M Paleologo
- EngageMinds HUB - Consumer, Food & Health Engagement Research Center, Università Cattolica del Sacro Cuore di Milano e Cremona, Milan and Cremona, Italy; Department of Psychology, Università Cattolica del Sacro Cuore di Milano, Milan, Italy
| | - G Graffigna
- EngageMinds HUB - Consumer, Food & Health Engagement Research Center, Università Cattolica del Sacro Cuore di Milano e Cremona, Milan and Cremona, Italy; Department of Psychology, Università Cattolica del Sacro Cuore di Milano, Milan, Italy; Faculty of Agricultural, Food and Environmental Sciences, Università Cattolica del Sacro Cuore di Cremona, Cremona, Italy
| | - S Barello
- Department of Brain and Behavioural Sciences, Università di Pavia, Pavia, Italy.
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Haley E, Luke N, Mathur M, Festa RA, Wang J, Jiang Y, Anderson LA, Baunoch D. The Prevalence and Association of Different Uropathogens Detected by M-PCR with Infection-Associated Urine Biomarkers in Urinary Tract Infections. Res Rep Urol 2024; 16:19-29. [PMID: 38221993 PMCID: PMC10787514 DOI: 10.2147/rru.s443361] [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: 10/06/2023] [Accepted: 12/16/2023] [Indexed: 01/16/2024] Open
Abstract
Background Many emerging uropathogens are currently identified by multiplex polymerase chain reaction (M-PCR) in suspected UTI cases. Standard urine culture (SUC) has significantly lower detection rates, raising questions about whether these organisms are associated with UTIs and truly cause inflammation. Objective To determine if microbes detected by M-PCR were likely causative of UTI by measuring inflammatory biomarkers in the urine of symptomatic patients. Design Setting and Participants Midstream voided urine was collected from subjects ≥60 years presenting to urology clinics with symptoms of UTI (n = 1132) between 01/2023 and 05/2023. Microbe detection was by M-PCR and inflammation-associated biomarker (neutrophil gelatinase-associated lipocalin, interleukin 8, and interleukin 1β) was by enzyme-linked immunosorbent assay. Biomarker positivity was measured against individual and groups of organisms, E. coli and non-E. coli cases, emerging uropathogens, monomicrobial and polymicrobial cases. Outcome Measurements and Statistical Analysis Distributions were compared using 2-sample Wilcoxon Rank Sum test with 2-tailed p-values < 0.05 considered statistically significant. Results and Limitations M-PCR was positive in 823 (72.7%) specimens with 28 of 30 (93%) microorganisms/groups detected. Twenty-six of twenty-eight detected microorganisms/groups (93%) had ≥2 biomarkers positive in >66% of cases. Both non-E. coli cases and E. coli cases had significant biomarker positivity (p < 0.05). Limitations were that a few organisms had low prevalence making inferences about their individual significance difficult. Conclusion The majority of microorganisms identified by M-PCR were associated with active inflammation measured by biomarker positivity, indicating they are likely causative of UTIs in symptomatic patients. This includes emerging uropathogens frequently not detected by standard urine culture.
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Affiliation(s)
- Emery Haley
- Department of Clinical Research, Pathnostics, Irvine, CA, USA
| | - Natalie Luke
- Department of Clinical Research, Pathnostics, Irvine, CA, USA
| | - Mohit Mathur
- Department of Medical Affairs, Pathnostics, Irvine, CA, USA
| | - Richard A Festa
- Department of Research and Development, Pathnostics, Irvine, CA, USA
| | - Jimin Wang
- Department of Statistical Analysis, Stat4Ward, Pittsburgh, PA, USA
| | - Yan Jiang
- Department of Statistical Analysis, Stat4Ward, Pittsburgh, PA, USA
| | - Lori A Anderson
- L.Anderson Diagnostic Market Access Consulting, San Diego, CA, USA
| | - David Baunoch
- Department of Research and Development, Pathnostics, Irvine, CA, USA
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Haley E, Luke N, Mathur M, Festa RA, Wang J, Jiang Y, Anderson L, Baunoch D. Comparison Shows that Multiplex Polymerase Chain Reaction Identifies Infection-associated Urinary Biomarker-positive Urinary Tract Infections That Are Missed by Standard Urine Culture. EUR UROL SUPPL 2023; 58:73-81. [PMID: 38152485 PMCID: PMC10751541 DOI: 10.1016/j.euros.2023.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2023] [Indexed: 12/29/2023] Open
Abstract
Background Multiplex polymerase chain reaction (M-PCR) has increased sensitivity for microbial detection compared with standard urine culture (SUC) in cases diagnosed as urinary tract infections (UTIs), leading to questions whether detected microbes are likely causative of UTIs or are incidental findings. Objective To compare infection-associated biomarker levels against M-PCR and SUC results in symptomatic cases with a presumptive diagnosis of a UTI by a urologist. Design setting and participants Participants were ≥60 yr old and presented to urology clinics between January and April 2023 with symptoms of UTIs (n = 583). Urine microbial detection was by M-PCR and SUC. Three infection-associated biomarkers (neutrophil gelatinase-associated lipocalin, interleukin-8, and interleukin-1β) were measured by enzyme-linked immunosorbent assay. Symptomatic cases with elevated biomarkers, detection of uropathogens, and a specialist clinical diagnosis of a UTI were considered definitive UTI cases. Outcome measurements and statistical analysis Distributions were compared using two-sample Wilcoxon rank sum test, with two-tailed p values of <0.05 considered statistically significant. Results and limitations In cases with M-PCR-positive/SUC-negative results (n = 80), all median biomarker levels were significantly higher (p < 0.0001) than in cases with M-PCR-negative/SUC-negative results (n = 107). Two or more biomarkers were positive in 76% of M-PCR-positive/SUC-negative specimens. Limitation was an inability to examine associations between each individual organism and inflammation. Conclusions A significant number of M-PCR-positive/SUC-negative cases had elevated levels of infection-related urinary biomarkers, especially when infection was caused by organisms other than Escherichia coli. This is a strong indication that microbes detected by M-PCR, which would be missed by SUC, are associated with UTIs. Patient summary We compared infection-associated biomarkers in patients diagnosed with urinary tract infections (UTIs) against the detection of microorganisms by standard urine culture (SUC) and multiplex polymerase chain reaction (M-PCR). We found that most patients with microorganisms detected by M-PCR, which were missed by SUC, had elevated markers of inflammation, indicating that these organisms were likely causative of UTIs.
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Affiliation(s)
- Emery Haley
- Department of Clinical Research, Pathnostics, Irvine, CA, USA
| | - Natalie Luke
- Department of Clinical Research, Pathnostics, Irvine, CA, USA
| | - Mohit Mathur
- Department of Medical Affairs, Pathnostics, Irvine, CA, USA
| | - Richard A. Festa
- Department of Research and Development, Pathnostics, Irvine, CA, USA
| | - Jimin Wang
- Department of Statistical Analysis, Stat4Ward, Pittsburgh, PA, USA
| | - Yan Jiang
- Department of Statistical Analysis, Stat4Ward, Pittsburgh, PA, USA
| | - Lori Anderson
- L. Anderson Diagnostic Market Access Consulting, San Diego, CA, USA
| | - David Baunoch
- Department of Research and Development, Pathnostics, Irvine, CA, USA
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Muteeb G. Network meta-analysis of antibiotic resistance patterns in gram-negative bacterial infections: a comparative study of carbapenems, fluoroquinolones, and aminoglycosides. Front Microbiol 2023; 14:1304011. [PMID: 38098660 PMCID: PMC10720636 DOI: 10.3389/fmicb.2023.1304011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 11/02/2023] [Indexed: 12/17/2023] Open
Abstract
Introduction Antimicrobial resistance poses a grave global threat, particularly with the emergence of multidrug-resistant gram-negative bacterial infections, which severely limit treatment options. The increasing global threat of antimicrobial resistance demands rigorous investigation, particularly concerning multidrug-resistant gram-negative bacterial infections that present limited therapeutic options. This study employed a network meta-analysis, a powerful tool for comparative effectiveness assessment of diverse antibiotics. The primary aim of this study was to comprehensively evaluate and compare resistance patterns among widely used antibiotic classes, namely carbapenems, fluoroquinolones, and aminoglycosides, for combating gram-negative pathogens. Methods We searched PubMed, Web of Sciences, Scopus, Scholarly, Medline, Embase, and Cochrane databases up to August 27, 2023. Studies showing antibiotic resistance in clinical isolates of Enterobacteriaceae, Pseudomonas aeruginosa, and Acinetobacter baumannii exposed to carbapenems, fluoroquinolones, and aminoglycosides were included. This study determined treatment-specific resistance percentages and ranked these treatments based on resistance using a random-effects network meta-analysis technique. To investigate the impact of the study and pathogen features, subgroup and meta-regression analyses were performed. Risk ratios and 95% confidence intervals (CIs) were calculated using a network meta-analysis (NMA) incorporating both direct and indirect evidence. Clinical improvement, cure, microbiological eradication, and death from any cause were the primary outcomes. Nephrotoxicity was a secondary result. Results The analysis included 202 publications and 365,782 gram-negative isolates. The NMA included data from 20 studies and 4,835 patients. Carbapenems had the lowest resistance rates throughout the pathogen spectrum, with resistance percentages of 17.1, 22.4, and 33.5% for Enterobacteriaceae, P. aeruginosa, and A. baumannii, respectively. For the same infections, aminoglycosides showed resistance rates of 28.2, 39.1, and 50.2%, respectively. Fluoroquinolones had the highest resistance rates at 43.1, 57.3, and 65.7%, respectively. Unexpectedly, resistance to all three antibiotic classes has increased over time, with multidrug resistance being the most prevalent. Conclusion This extensive network meta-analysis provides an overview of the patterns of resistance throughout the world and how they are changing. The most effective choice is still carbapenems, but the increasing resistance highlights the critical need for multimodal therapies to protect antibiotic effectiveness against these powerful gram-negative infections.
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Affiliation(s)
- Ghazala Muteeb
- Department of Nursing, College of Applied Medical Science, King Faisal University, Al-Ahsa, Saudi Arabia
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Haley E, Luke N, Korman H, Baunoch D, Wang D, Zhao X, Mathur M. Improving Patient Outcomes While Reducing Empirical Treatment with Multiplex-Polymerase-Chain-Reaction/Pooled-Antibiotic-Susceptibility-Testing Assay for Complicated and Recurrent Urinary Tract Infections. Diagnostics (Basel) 2023; 13:3060. [PMID: 37835804 PMCID: PMC10573050 DOI: 10.3390/diagnostics13193060] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/07/2023] [Accepted: 09/18/2023] [Indexed: 10/15/2023] Open
Abstract
This study compared rates of empirical-therapy use and negative patient outcomes between complicated and recurrent urinary tract infection (r/cUTI) cases diagnosed with a multiplex polymerase chain reaction or pooled antibiotic susceptibility testing (M-PCR/P-AST) vs. standard urine culture (SUC). Subjects were 577 symptomatic adults (n = 207 males and n = 370 females) presenting to urology/urogynecology clinics between 03/30/2022 and 05/24/2023. Treatment and outcomes were recorded by the clinician and patient surveys. The M-PCR/P-AST (n = 252) and SUC (n = 146) arms were compared after patient matching for confounding factors. The chi-square and Fisher's exact tests were used to analyze demographics and clinical outcomes between study arms. Reduced empirical-treatment use (28.7% vs. 66.7%), lower composite negative events (34.5% vs. 46.6%, p = 0.018), and fewer individual negative outcomes of UTI-related medical provider visits and UTI-related visits for hospitalization/an urgent care center/an emergency room (p < 0.05) were observed in the M-PCR/P-AST arm compared with the SUC arm. A reduction in UTI symptom recurrence in patients ≥ 60 years old was observed in the M-PCR/P-AST arm (p < 0.05). Study results indicate that use of the M-PCR/P-AST test reduces empirical antibiotic treatment and negative patient outcomes in r/cUTI cases.
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Affiliation(s)
- Emery Haley
- Department of Clinical Research, Pathnostics, Irvine, CA 92618, USA; (E.H.); (N.L.)
| | - Natalie Luke
- Department of Clinical Research, Pathnostics, Irvine, CA 92618, USA; (E.H.); (N.L.)
| | - Howard Korman
- Department of Urology, Comprehensive Urology—A Division of Michigan Healthcare Professionals, Royal Oak, MI 48073, USA;
| | - David Baunoch
- Department of Research and Development, Pathnostics, Irvine, CA 92618, USA;
| | - Dakun Wang
- Department of Scientific Writing, Stat4Ward, Pittsburgh, PA 15238, USA;
| | - Xinhua Zhao
- Department of Statistical Analysis, Stat4Ward, Pittsburgh, PA 15238, USA;
| | - Mohit Mathur
- Department of Medical Affairs, Pathnostics, Irvine, CA 92618, USA
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9
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Nguyen HM, Flerchinger S, Smith JR, Felcher AH, Turley M, Mcnamara M. Diagnostic and antibiotic stewardship lessons: an outpatient assessment of symptomatic reflex urinalysis ordering accuracy using an electronic best-practice alert. J Antimicrob Chemother 2023; 78:2283-2290. [PMID: 37492974 DOI: 10.1093/jac/dkad233] [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: 01/29/2023] [Accepted: 07/12/2023] [Indexed: 07/27/2023] Open
Abstract
BACKGROUND It is not well known how reliably clinicians order reflex urinalysis to microscopy and culture (rUA-cx) for outpatient urinary tract infection (UTI) workup. Antibiotic appropriateness cannot be fully appreciated until the prevalence of UTIs and asymptomatic bacteriuria (ASB) are realized. OBJECTIVE This quality improvement study has two major aims, first to determine UTI symptom accuracy for rUA-cx ordering and second, to confirm UTI and ASB cases by integrating rUA-cx and cascaded urinalysis results. Antibiotic utilization and diagnostic coding were secondarily linked to UTIs and ASB. METHODS An electronic best-practice alert informed the ordering of two rUA-cx options: symptomatic- rUA-cx specifically for dysuria, frequency, urgency, costovertebral pain, suprapubic pain or fever versus non-specific-rUA-cx for vague complaints. UTI symptoms were verified by chart review. Confirmed UTI was defined as a significant culture with UTI symptoms and ASB as a significant culture without UTI symptoms. RESULTS rUA-cx (2065) were prospectively collected over 6 months from female patients at risk for uncomplicated UTIs. Symptomatic-rUA-cx and non-specific-rUA-cx were associated with UTI symptoms for 53% (809/1527) and 20% (107/538), respectively. Overall, 44% (916/2065) of all rUA-cx had UTI symptoms. rUA-cx were overordered by a factor of 9 (2065/225) for every confirmed UTI. The UTI-to-ASB relative ratio was 2.6 (225/86). Regarding UTI-relevant antibiotics, 39% (214/553) were appropriately associated with UTI whereas only 22% (74/339) of inappropriate antibiotics were captured by the ASB definition, underestimating the problem 4-fold. CONCLUSIONS UTI and ASB remain challenging to categorize despite a meticulous method that applied acceptable criteria.
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Affiliation(s)
- Hien M Nguyen
- Department of Infectious Diseases, Northwest Permanente, Portland, Oregon, USA
| | | | - Jeffrey R Smith
- Kaiser Permanente Northwest Region Laboratories, Portland, Oregon, USA
- The Permanente Federation, Convergent Medical Terminology, Oakland, California, USA
| | - Andrew H Felcher
- Department of Hospital Medicine, Northwest Permanente, Portland, Oregon, USA
| | | | - Michael Mcnamara
- Department of Medical Informatics, Northwest Permanente, Portland, Oregon, 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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Cox S, Lo-A-Foe K, van Hoof M, Dinant GJ, Oudhuis G, Savelkoul P, Cals J, de Bont E. Physician-Targeted Interventions in Antibiotic Prescribing for Urinary Tract Infections in General Practice: A Systematic Review. Antibiotics (Basel) 2022; 11:1560. [PMID: 36358215 PMCID: PMC9686805 DOI: 10.3390/antibiotics11111560] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 10/25/2022] [Accepted: 11/03/2022] [Indexed: 07/30/2023] Open
Abstract
Urinary tract infections (UTIs) are the most common reason for women to consult a general practitioner (GP). While UTIs are self-limiting in half of cases, most women are prescribed antibiotics, often in discordance with established guidelines. Researchers have employed different interventions to improve GPs' prescribing behavior, especially for respiratory infections, but it is uncertain whether these are effective for UTI care. Therefore, we performed a systematic review, including (cluster) randomized clinical trials investigating the effect of interventions targeted at GPs to improve antibiotic prescriptions for UTI. From September to December 2021 we searched the Medline, Web of Science, and CENTRAL databases, ultimately including ten studies describing eleven trials. We determined the effect of the interventions on the decision to prescribe and on the choice of antibiotic. Results showed that most studies employed multifaceted interventions, most frequently including audit & feedback and/or educational meetings. Seven out of nine trials that recorded first-choice prescriptions saw an increased proportion of first-choice antibiotics in the intervention groups compared to control groups. The employed interventions also caused a decreased proportion of at least one broad-spectrum antibiotic in five out of six studies that measured broad-spectrum antibiotic prescriptions. However, the total number of antibiotic prescriptions for UTIs increased in four out of eight studies. Therefore, while effective at influencing GPs' prescribing behavior, future interventions should also focus on improving the decision to prescribe at all.
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Affiliation(s)
- Stefan Cox
- Department of Family Medicine, Maastricht University, P. Debyeplein 1, 6229 HA Maastricht, The Netherlands
| | - Kelly Lo-A-Foe
- Department of Family Medicine, Maastricht University, P. Debyeplein 1, 6229 HA Maastricht, The Netherlands
| | - Minke van Hoof
- Department of Family Medicine, Maastricht University, P. Debyeplein 1, 6229 HA Maastricht, The Netherlands
| | - Geert-Jan Dinant
- Department of Family Medicine, Maastricht University, P. Debyeplein 1, 6229 HA Maastricht, The Netherlands
| | - Guy Oudhuis
- Department of Medical Microbiology, Maastricht University Medical Centre+, Universiteitssingel 40, 6229 ER Maastricht, The Netherlands
| | - Paul Savelkoul
- Department of Medical Microbiology, Maastricht University Medical Centre+, Universiteitssingel 40, 6229 ER Maastricht, The Netherlands
| | - Jochen Cals
- Department of Family Medicine, Maastricht University, P. Debyeplein 1, 6229 HA Maastricht, The Netherlands
| | - Eefje de Bont
- Department of Family Medicine, Maastricht University, P. Debyeplein 1, 6229 HA Maastricht, The Netherlands
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12
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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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13
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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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14
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Sankar A, Swanson KM, Zhou J, Jena AB, Ross JS, Shah ND, Karaca-Mandic P. Association of Fluoroquinolone Prescribing Rates With Black Box Warnings from the US Food and Drug Administration. JAMA Netw Open 2021; 4:e2136662. [PMID: 34851398 PMCID: PMC8637256 DOI: 10.1001/jamanetworkopen.2021.36662] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
IMPORTANCE In 2013 and 2016, the US Food and Drug Administration (FDA) issued warnings and recommended limited use of fluoroquinolones for patients with certain acute conditions. It is not clear how prescribers have responded to these warnings. OBJECTIVE To analyze changes in prescribing of fluoroquinolones after the 2013 and 2016 FDA warnings and to examine the physician characteristics associated with these changes. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used Medicare administrative claims data on Medicare fee-for-service beneficiaries and OneKey data on physicians and their organizations from January 1, 2011, to December 31, 2017. The sample was restricted to outpatient visits for sinusitis, bronchitis, and uncomplicated urinary tract infections. An interrupted time series approach was used to analyze the changes in the prescription rate after each FDA warning. Data analysis was performed between January 1, 2011, and December 31, 2017. INTERVENTIONS Two FDA black box warnings released in August 2013 and July 2016. MAIN OUTCOMES AND MEASURES The main outcome was an indicator for fluoroquinolone prescriptions in 3 periods: before the 2013 warning (baseline period), after the 2013 warning but before the 2016 warning (postwarning period 1), and after the 2016 warning (postwarning period 2). RESULTS The sample comprised 1 238 397 unique patients with a total of 2 720 071 outpatient acute care visits. Of this sample, 848 360 were women (68.5%), and the mean (SD) age was 69.7 (12.6) years. The immediate prescribing levels of fluoroquinolones in postwarning period 1 increased by 3.42 percentage points (95% CI, 3.23-3.62; P < .001) and declined by -0.77 percentage points (95% CI, -1.00 to -0.54; P < .001) in postwarning period 2. The prescribing trend increased by 0.08 percentage points per month (95% CI, 0.08-0.10; P < .001) in postwarning period 1 and 0.06 percentage points per month (95% CI, 0.04-0.08; P < .001) in postwarning period 2. In postwarning period 1, the prescribing levels for physicians who were affiliated with hospitals with a top 10th percentile case mix index vs those without such affiliation decreased by -1.13 percentage points (95% CI, -1.92 to -0.34; P = .005), whereas the levels for primary care physicians declined by -1.34 percentage points (95% CI, -1.78 to -0.88; P < .001) compared with non-primary care physicians in postwarning period 2. Physicians at teaching hospitals were the only ones who showed a decline in prescribing trend in postwarning period 1. CONCLUSIONS AND RELEVANCE This cross-sectional study found an overall decline in prescribing of fluoroquinolones after the release of FDA warnings. Understanding the association of physician and organizational characteristics with fluoroquinolone prescribing behavior may ultimately help to identify mechanisms to improve de-adoption.
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Affiliation(s)
- Ashwini Sankar
- Carlson School of Management, Department of Finance, University of Minnesota, Minneapolis
- Department of Economics, Macalester College, St Paul, Minnesota
| | - Kristi M. Swanson
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Jiani Zhou
- School of Public Health, University of Minnesota, Minneapolis
| | - Anupam Bapu Jena
- Department of Health Care Policy, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Joseph S. Ross
- Yale University, Yale School of Medicine, New Haven, Connecticut
| | - Nilay D. Shah
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota
| | - Pinar Karaca-Mandic
- Carlson School of Management, Department of Finance, University of Minnesota, Minneapolis
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15
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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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16
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Butler AM, Durkin MJ, Keller MR, Ma Y, Dharnidharka VR, Powderly WG, Olsen MA. Risk of antibiotic treatment failure in premenopausal women with uncomplicated urinary tract infection. Pharmacoepidemiol Drug Saf 2021; 30:1360-1370. [PMID: 33783918 DOI: 10.1002/pds.5237] [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: 11/23/2020] [Revised: 03/10/2021] [Accepted: 03/19/2021] [Indexed: 11/11/2022]
Abstract
PURPOSE Acute uncomplicated urinary tract infections (UTIs) are among the most common indications for antibiotic prescriptions in otherwise healthy women. We compared the risk of treatment failure of antibiotic regimens for outpatient treatment of UTI in real-world practice. METHODS We identified non-pregnant, premenopausal women diagnosed with uncomplicated, lower tract UTI and prescribed an oral antibiotic with activity against common uropathogens. We used propensity score-weighted Kaplan-Meier functions to estimate 30-day risks and risk differences (RD) for pyelonephritis and UTI-related antibiotic prescription switch. RESULTS Of 1 140 602 patients, the distribution of index prescriptions was 44% fluoroquinolones (non-first-line), 28% trimethoprim-sulfamethoxazole (TMP/SMX) (first-line), 24% nitrofurantoin (first-line), 3% narrow-spectrum β-lactams (non-first-line), 1% broad-spectrum β-lactams (non-first-line), and 1% amoxicillin/ampicillin (non-recommended). Compared to the risk of pyelonephritis for nitrofurantoin (0.3%), risks were higher for TMP/SMX (RD, 0.2%; 95% CI, 0.2%-0.2%) and broad-spectrum β-lactams (RD, 0.2%; 95% CI, 0.1%-0.4%). Compared to the risk of prescription switch for nitrofurantoin (12.7%), the risk was higher for TMP/SMX (RD 1.6%; 95% CI 1.3%-1.7%) but similar for broad-spectrum β-lactams (RD -0.7%; 95% CI -1.4%-0.1%) and narrow-spectrum β-lactams (RD -0.3%; 95% CI -0.8%-0.2%). Subgroup analyses suggest TMP/SMX treatment failure may be due in part to increasing uropathogen resistance over time. CONCLUSIONS The risk of treatment failure differed by antibiotic agent, with higher risk associated with TMP/SMX versus nitrofurantoin, and lower or similar risk associated with broad- versus narrow-spectrum β-lactams. Given serious safety warnings for fluoroquinolones, these results suggest that nitrofurantoin may be preferable as the first-line agent for outpatient treatment of uncomplicated UTI.
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Affiliation(s)
- Anne M Butler
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA.,Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Michael J Durkin
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Matthew R Keller
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Yinjiao Ma
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Vikas R Dharnidharka
- Department of Pediatrics, Division of Pediatric Nephrology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - William G Powderly
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Margaret A Olsen
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA.,Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, Missouri, USA
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17
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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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18
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Abbott IJ, Roberts JA, Meletiadis J, Peleg AY. Antimicrobial pharmacokinetics and preclinical in vitro models to support optimized treatment approaches for uncomplicated lower urinary tract infections. Expert Rev Anti Infect Ther 2020; 19:271-295. [PMID: 32820686 DOI: 10.1080/14787210.2020.1813567] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Urinary tract infections (UTIs) are extremely common. Millions of people, particularly healthy women, are affected worldwide every year. One-in-two women will have a recurrence within 12-months of an initial UTI. Inadequate treatment risks worsening infection leading to acute pyelonephritis, bacteremia and sepsis. In an era of increasing antimicrobial resistance, it is critical to provide optimized antimicrobial treatment. AREAS COVERED Literature was searched using PubMed and Google Scholar (up to 06/2020), examining the etiology, diagnosis and oral antimicrobial therapy for uncomplicated UTIs, with emphasis on urinary antimicrobial pharmacokinetics (PK) and the application of dynamic in vitro models for the pharmacodynamic (PD) profiling of pathogen response. EXPERT OPINION The majority of antimicrobial agents included in international guidelines were developed decades ago without well-described dose-response relationships. Microbiology laboratories still apply standard diagnostic methodology that has essentially remained unchanged for decades. Furthermore, it is uncertain how relevant standard in vitro susceptibility is for predicting antimicrobial efficacy in urine. In order to optimize UTI treatments, clinicians must exploit the urine-specific PK of antimicrobial agents. Dynamic in vitro models are valuable tools to examine the PK/PD and urodynamic variables associated with UTIs, while informing uropathogen susceptibility reporting, optimized dosing schedules, clinical trials and treatment guidelines.
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Affiliation(s)
- Iain J Abbott
- Department of Infectious Diseases, the Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia.,School of Pharmacy, Centre for Translational Anti-infective Pharmacodynamics, The University of Queensland, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Joseph Meletiadis
- Clinical Microbiology Laboratory, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Haidari, Greece
| | - Anton Y Peleg
- Department of Infectious Diseases, the Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia.,Infection and Immunity Program, Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Australia
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19
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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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21
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Lonsdale DO, Lipman J. Antimicrobial Resistance: We Must Pursue a Collaborative, Global Approach and Use a "One Health" Approach. Antibiotics (Basel) 2019; 8:antibiotics8040237. [PMID: 31783648 PMCID: PMC6963947 DOI: 10.3390/antibiotics8040237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 11/25/2019] [Indexed: 02/01/2023] Open
Affiliation(s)
- Dagan O Lonsdale
- Department of Intensive Care Medicine, St George’s University Hospitals NHS Foundation Trust, London SW17 0QT, UK;
- Department of Clinical Pharmacology and Therapeutics, St George’s, University of London, London SW17 0RE, UK
| | - Jeffrey Lipman
- Royal Brisbane and Womens’ Hospital, University of Queensland, Brisbane 4029, Australia
- Nimes University Hospital, University of Montpellier, 30029 Nimes, France
- Correspondence: ; Tel.: +61-7-3636-8897; Fax: +61-7-3636-3542
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