Long-term impact of fluoroquinolone-sparing strategies for empirical treatment of acute uncomplicated cystitis among ambulatory patients

Abstract

Background: Acute uncomplicated cystitis is common among outpatients and frequently leads to antibiotic prescriptions, making urinary tract infections (UTIs) an important area for antimicrobial stewardship initiatives. Infectious Disease Society of America (IDSA) guidelines promote alternative agents in place of fluoroquinolones for acute uncomplicated cystitis. Despite IDSA guidance, adherence to the guideline remains low in the United States (US). Several studies have described interventions to improve guideline-concordant prescribing for UTIs. However, the long-term sustainability and impact of fluoroquinolone (FLQ)-sparing strategies on community antimicrobial resistance and treatment outcomes are unknown. The objectives of this study were to characterize current antibiotic prescribing patterns, treatment failures and Escherichia coli resistance rates in a setting which instituted FLQ sparing strategies for UTIs in 2007. Methods: Retrospective cohort study of women aged ⩾ 18 diagnosed with acute uncomplicated cystitis based on International Classification of Diseases, 10th Revision (ICD-10) codes were included. Data were abstracted for ambulatory visits over a 6-month period, January 2018 to June 2018, at a large urban health care system. Treatment decisions were made by individual providers, and data were analyzed retrospectively. Nitrofurantoin (NFT) resistance was obtained from the institutional antibiogram and patient-level data. Treatment failure was defined as the need for a different antibiotic for UTI within 28 days of the original prescription. Results: NFT was the most frequently prescribed antibiotic ( n = 386, 71.6%) of empiric antibiotic prescriptions for UTIs. FLQs comprised 4.6% of all antibiotic prescriptions ( n = 25). Treatment failure rate was 2.3% in patients treated with NFT. Urine culture was ordered for only 26.8% of patients. Among the small group of patients with cultures ordered, E. coli remained 98.5% susceptible to NFT. Conclusions: This study is the first to report significantly low rates (4.6%) of FLQ prescribing for acute uncomplicated cystitis. Treatment failure rate was low with empiric NFT. Increased NFT resistance among E. coli was not observed at the institution or among the subset of patients with E. coli positive urine cultures. These findings support current IDSA treatment guidance for uncomplicated cystitis.

SWOT and Root Cause Analyses of Antimicrobial Resistance to Oral Antimicrobial Treatment of Cystitis

“…While absorbed OAT can reach pathogens in upper urinary tracts via perfused blood, the uropathogens causing cystitis can only be eliminated by the urinary fraction of absorbed OAT (Figure 2), because the circulating levels [126,127,130] of the drug are less likely to reach the planktonic microbes and those attaching to the apical side of umbrella cells (Figure 1); (3) The battle between OAT and the uropathogens provoking cystitis is heavily influenced by the physiology of urine flow [20,25,113] and drug physiochemistry [107,132]; (4) The principle of the five Ds-drug, dose, duration, drug route, and de-escalation-for AMS [44] advocates for obtaining the right drug concentration in urine above the MIC (Figures 2-5) [124,154]. The principle of the five "Ds" can be best illustrated by an intravesical gentamicin dose of 80 mg [155][156][157][158][159] (Figure 5B), delivering a bactericidal concentration with a 90% elimination of live bacteria within 3 h of administration, with a comparative lower incidence of AMR [140] and recurrence [37] than those reported with OAT [38,123]. As opposed to the urine and plasma plots of OAT shown in Figure 2B, the plot in Figure 5B is projected from a recent study on post-operative prophylaxis by intravesical gentamicin [160].…”

“…As opposed to the urine and plasma plots of OAT shown in Figure 2B, the plot in Figure 5B is projected from a recent study on post-operative prophylaxis by intravesical gentamicin [160]. As depicted by the low plasma levels (red curve in Figure 5B), the limited The principle of the five "Ds" can be best illustrated by an intravesical gentamicin dose of 80 mg [155][156][157][158][159] (Figure 5B), delivering a bactericidal concentration with a 90% elimination of live bacteria within 3 h of administration, with a comparative lower incidence of AMR [140] and recurrence [37] than those reported with OAT [38,123]. As opposed to the urine and plasma plots of OAT shown in Figure 2B, the plot in Figure 5B is projected from a recent study on post-operative prophylaxis by intravesical gentamicin [160].…”

The Essential Role of PCR and PCR Panel Size in Comparison with Urine Culture in Identification of Polymicrobial and Fastidious Organisms in Patients with Complicated Urinary Tract Infections

“…UTIs are extremely common, affecting more than 10 million patients in the United States each year [ 1 ]. Most UTI are uncomplicated type, defined as a lower tract infection without associated anatomic abnormalities and resolved with appropriate treatment [ 2 , 3 , 4 ]. Complicated urinary tract infections (cUTIs) are generally accepted to be any UTI that fails to meet the criteria for simple UTI, and as such, encompasses a wide variety of conditions, including patients who have recurrent uncomplicated UTI despite adequate treatment but have prolonged symptoms or rapid recurrence of symptoms [ 5 ], those that present with underlying anatomic abnormalities, concomitant comorbidities (urologic or systemic), as well as recent hospitalization or genitourinary instrumentation [ 6 , 7 ].…”