Proper Antibiotic Use in a Home-Based Primary Care Population Treated for Urinary Tract Infections

Abstract Background Consultations in primary care for symptoms of urinary tract infections (UTIs) are common and patients are frequently treated with antibiotics. Given increasing antimicrobial resistance, there has been interest in non-antibiotic treatment options for common infections. One such option is the use of cranberry extract to treat symptoms attributable to UTIs. Methods A target of 45 women consulting in primary care, with symptoms suggestive of an uncomplicated UTI for whom the practitioner would normally prescribe antibiotics, will be randomised to receive one of three treatment approaches: (1) immediate prescription for antibiotics; (2) immediate prescription for antibiotics plus a 7-day course of cranberry capsules and (3) cranberry capsules plus a delayed prescription for antibiotics to be used in case their symptoms do not get better, or get worse. Follow-up will be by daily rating of symptoms and recording of treatments used for 2 weeks in an online symptom diary. Interviews will be conducted with around 10–15 study participants, as well as with around 10–15 women who have experienced a UTI but have not been approached to take part in the study. Both groups will be asked about their experience of having a UTI, their thoughts on non-antibiotic treatments for UTIs and their thoughts on, or experience of, the feasibility trial. The primary objective is to assess the feasibility of undertaking a full trial in primary care of the effectiveness of cranberry extract to reduce antibiotic use for symptoms of acute uncomplicated UTI. The secondary objective is to conduct a preliminary assessment of the extent to which cranberry might reduce antibiotic use and symptom burden. Discussion This feasibility study with embedded interviews will inform the planning and sample size calculation of an adequately powered trial to definitively determine whether cranberry helps to alleviate the symptoms of acute uncomplicated UTIs in women and whether it can safely reduce antibiotic use. Trial registration ISRCTN registry, ID: 10399299. Registered on 24 January 2019.

Download Full-text

Selection and co-selection of antibiotic resistances among Escherichia coli by antibiotic use in primary care: an ecological analysis

10.1101/573360 ◽

2019 ◽

Cited By ~ 1

Author(s):

Koen B Pouwels ◽

Berit Muller-Pebody ◽

Timo Smieszek ◽

Susan Hopkins ◽

Julie V Robotham

Keyword(s):

Escherichia Coli ◽

Primary Care ◽

Antibiotic Resistance ◽

Urinary Tract ◽

Respiratory Tract ◽

Urinary Tract Infections ◽

Respiratory Tract Infections ◽

Antibiotic Use ◽

E Coli ◽

Tract Infections

AbstractThe majority of studies that link antibiotic usage and resistance focus on simple associations between the resistance against a specific antibiotic and the use of that specific antibiotic. However, the relationship between antibiotic use and resistance is more complex. Here we evaluate which antibiotics, including those mainly prescribed for respiratory tract infections, are associated with increased resistance among Escherichia coli isolated from urinary samples.Monthly primary care prescribing data were obtained from National Health Service (NHS) Digital. Positive E. coli records from urine samples in English primary care (n=888,207) between April 2014 and January 2016 were obtained from the Second Generation Surveillance System. Elastic net regularization was used to evaluate associations between prescribing of different antibiotic groups and resistance against amoxicillin, cephalexin, ciprofloxacin, co-amoxiclav and nitrofurantoin at the clinical commissioning group (CCG) level. England is divided into 209 CCGs, with each NHS practice prolonging to one CCG.Amoxicillin prescribing (measured in DDD/ 1000 inhabitants / day) was positively associated with amoxicillin (RR 1.03, 95% CI 1.01 – 1.04) and ciprofloxacin (RR 1.09, 95% CI 1.04 – 1.17) resistance. In contrast, nitrofurantoin prescribing was associated with lower levels of resistance to amoxicillin (RR 0.92, 95% CI 0.84 – 0.97). CCGs with higher levels of trimethoprim prescribing also had higher levels of ciprofloxacin resistance (RR 1.34, 95% CI 1.10 – 1.59).Amoxicillin, which is mainly (and often unnecessarily) prescribed for respiratory tract infections is associated with increased resistance against various antibiotics among E. coli causing urinary tract infections. Our findings suggest that when predicting the potential impact of interventions on antibiotic resistances it is important to account for use of other antibiotics, including those typically used for other indications.Author summaryAntibiotic resistance is increasingly recognised as a threat to modern healthcare. Effective antibiotics are crucial for treatment of serious bacterial infections and are necessary to avoid that complicated surgical procedures and chemotherapy becoming life-threatening. Antibiotic use is one of the main drivers of antibiotic resistance. The majority of antibiotic prescriptions are prescribed in primary care, however, a large proportion of these antibiotic prescriptions are unnecessary. Understanding which antibiotics are causing antibiotic resistance to what extent is needed to prevent under- or over-investment in interventions lowering use of specific antibiotics, such as rapid diagnostic tests for respiratory tract infection.We have statistically evaluated which antibiotics are associated with higher and lower levels of antibiotic resistance against common antibiotics among Escherichia coli bacteria sampled from the urinary tract by comparing antibiotic prescribing and resistance in different geographical areas in England. Our model shows that amoxicillin, the most commonly used antibiotic in England and mainly used for respiratory tract infections, is associated with increased resistance against several other antibiotics among bacteria causing urinary tract infections. The methods used in this study, that overcome several of the limitations of previous studies, can be used to explore the complex relationships between antibiotic use and antibiotic resistance in other settings.

Download Full-text

The Five Ds of Outpatient Antibiotic Stewardship for Urinary Tract Infections

Clinical Microbiology Reviews ◽

10.1128/cmr.00003-20 ◽

2021 ◽

Author(s):

Melanie C. Goebel ◽

Barbara W. Trautner ◽

Larissa Grigoryan

Keyword(s):

Primary Care ◽

Antibiotic Resistance ◽

Urinary Tract ◽

Urinary Tract Infections ◽

Emergency Departments ◽

Antibiotic Stewardship ◽

Antibiotic Use ◽

Outpatient Setting ◽

Outpatient Clinics ◽

Tract Infections

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.

Download Full-text

Urinary tract infections (UTIs); a leaflet for older adults, and carers: the development of a UTI leaflet for older adults and their carers

British Journal of General Practice ◽

10.3399/bjgp18x696833 ◽

2018 ◽

Vol 68 (suppl 1) ◽

pp. bjgp18X696833 ◽

Cited By ~ 1

Author(s):

Leah Ffion Jones ◽

Emily Cooper ◽

Cliodna McNulty

Keyword(s):

Older Adults ◽

Urinary Tract ◽

Urinary Tract Infections ◽

Care Home ◽

Asymptomatic Bacteriuria ◽

Theoretical Domains Framework ◽

Antibiotic Use ◽

Primary Care Providers ◽

Care Providers ◽

Tract Infections

BackgroundEscherichia coli bacteraemia rates are rising with highest rates in older adults. Mandatory surveillance identifies previous Urinary Tract Infections (UTI) and catheterisation as risk factors.AimTo help control bacteraemias in older frail patients by developing a patient leaflet around the prevention and self-care of UTIs informed by the Theoretical Domains Framework.MethodFocus groups or interviews were held with care home staff, residents and relatives, GP staff and an out of hours service, public panels and stakeholders. Questions explored diagnosis, management, prevention of UTIs and antibiotic use in older adults. The leaflet was modified iteratively. Discussions were transcribed and analysed using Nvivo.ResultsCarers of older adults reported their important role in identifying when older adults might have a UTI, as they usually flag symptoms to nurses or primary care providers. Information on UTIs needs to be presented so residents can follow; larger text and coloured sections were suggested. Carers were optimistic that the leaflet could impact on the way UTIs are managed. Older adults and relatives liked that it provided new information to them. Staff welcomed that diagnostic guidance for UTIs was being developed in parallel; promoting consistent messages. Participants welcomed and helped to word sections on describing asymptomatic bacteriuria simply, preventing UTIs, causes of confusion and when to contact a doctor or nurseConclusionA final UTI leaflet for older adults has been developed informed by the TDF. See the TARGET website www.RCGP.org.uk/targetantibiotics/

Download Full-text

1675. Epidemiology of Urinary Tract Infections in the United States, 2009 - 2018

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.1853 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S823-S823

Author(s):

Kendra Foster ◽

Linnea A Polgreen ◽

Brett Faine ◽

Philip M Polgreen

Keyword(s):

United States ◽

Urinary Tract ◽

Klebsiella Pneumoniae ◽

Urinary Tract Infections ◽

Proteus Mirabilis ◽

Antibiotic Use ◽

The United States ◽

Drug Resistant ◽

E Coli ◽

Tract Infections

Abstract Background Urinary tract infections (UTIs) are one of the most common bacterial infections. There is a lack of large epidemiologic studies evaluating the etiologies of UTIs in the United States. This study aimed to determine the prevalence of different UTI-causing organisms and their antimicrobial susceptibility profiles among patients being treated in a hospital setting. Methods We used the Premier Healthcare Database. Patients with a primary diagnosis code of cystitis, pyelonephritis, or urinary tract infection and had a urine culture from 2009- 2018 were included in the study. Both inpatients and patients who were only treated in the emergency department (ED) were included. We calculated descriptive statistics for uropathogens and their susceptibilities. Multi-drug-resistant pathogens are defined as pathogens resistant to 3 or more antibiotics. Resistance patterns are also described for specific drug classes, like resistance to fluoroquinolones. We also evaluated antibiotic use in this patient population and how antibiotic use varied during the hospitalization. Results There were 640,285 individuals who met the inclusion criteria. Females make up 82% of the study population and 45% were age 65 or older. The most common uropathogen was Escherichia Coli (64.9%) followed by Klebsiella pneumoniae (8.3%), and Proteus mirabilis (5.7%). 22.2% of patients were infected with a multi-drug-resistant pathogen. We found that E. Coli was multi-drug resistant 23.8% of the time; Klebsiella pneumoniae was multi-drug resistant 7.4%; and Proteus mirabilis was multi-drug resistant 2.8%. The most common antibiotics prescribed were ceftriaxone, levofloxacin, and ciprofloxacin. Among patients that were prescribed ceftriaxone, 31.7% of them switched to a different antibiotic during their hospitalization. Patients that were prescribed levofloxacin and ciprofloxacin switched to a different antibiotic 42.8% and 41.5% of the time, respectively. Conclusion E. Coli showed significant multidrug resistance in this population of UTI patients that were hospitalized or treated within the ED, and antibiotic switching is common. Disclosures All Authors: No reported disclosures

Download Full-text

PD10-09 GENTAMICIN INTRAVESICAL INSTILLATIONS DECREASE SYMPTOMATIC URINARY TRACT INFECTIONS AND ORAL ANTIBIOTIC USE IN PATIENTS WITH NEUROGENIC BLADDER ON INTERMITTENT CATHETERIZATION

The Journal of Urology ◽

10.1016/j.juro.2015.02.949 ◽

2015 ◽

Vol 193 (4S) ◽

Author(s):

Lindsey Cox ◽

J. Quentin Clemens ◽

Anne Cameron

Keyword(s):

Urinary Tract ◽

Neurogenic Bladder ◽

Urinary Tract Infections ◽

Antibiotic Use ◽

Intermittent Catheterization ◽

Oral Antibiotic ◽

Tract Infections ◽

Intravesical Instillations

Download Full-text

An Assessment of Inappropriate Antibiotic Use and Guideline Adherence for Uncomplicated Urinary Tract Infections

Open Forum Infectious Diseases ◽

10.1093/ofid/ofy198 ◽

2018 ◽

Vol 5 (9) ◽

Cited By ~ 27

Author(s):

Michael J Durkin ◽

Matthew Keller ◽

Anne M Butler ◽

Jennie H Kwon ◽

Erik R Dubberke ◽

...

Keyword(s):

Urinary Tract ◽

Urinary Tract Infections ◽

Antibiotic Use ◽

Emergency Department Visits ◽

Antibiotic Prescribing ◽

Prescribing Practices ◽

Duration Of Treatment ◽

Minimal Impact ◽

Tract Infections ◽

The Impact

Abstract Background In 2011, The Infectious Diseases Society of America released a clinical practice guideline (CPG) that recommended short-course antibiotic therapy and avoidance of fluoroquinolones for uncomplicated urinary tract infections (UTIs). Recommendations from this CPG were rapidly disseminated to clinicians via review articles, UpToDate, and the Centers for Disease Control and Prevention website; however, it is unclear if this CPG had an impact on national antibiotic prescribing practices. Methods We performed a retrospective cohort study of outpatient and emergency department visits within a commercial insurance database between January 1, 2009, and December 31, 2013. We included nonpregnant women aged 18–44 years who had an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code for a UTI with a concurrent antibiotic prescription. We performed interrupted time series analyses to determine the impact of the CPG on the appropriateness of the antibiotic agent and duration. Results We identified 654 432 women diagnosed with UTI. The patient population was young (mean age, 31 years) and had few comorbidities. Fluoroquinolones, nonfirstline agents, were the most commonly prescribed antibiotic class both before and after release of the guidelines (45% vs 42%). Wide variation was observed in the duration of treatment, with >75% of prescriptions written for nonrecommended treatment durations. The CPG had minimal impact on antibiotic prescribing behavior by providers. Conclusions Inappropriate antibiotic prescribing is common for the treatment of UTIs. The CPG was not associated with a clinically meaningful change in national antibiotic prescribing practices for UTIs. Further interventions are necessary to improve outpatient antibiotic prescribing for UTIs.

Download Full-text

1475. Understanding Prescribing Practices for Uncomplicated Urinary Tract Infections (UTIs) in the Primary Care Setting: A Pilot Study

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.1339 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S538-S538

Author(s):

Mark Pinkerton ◽

Jahnavi Bongu ◽

Aimee James ◽

Michael Durkin

Keyword(s):

Primary Care ◽

Urinary Tract ◽

Urinary Tract Infections ◽

Clinical Decision ◽

Primary Care Providers ◽

Care Providers ◽

Prescribing Practices ◽

Support Tools ◽

Tract Infections ◽

Clinical Decision Support Tools

Abstract Background Uncomplicated urinary tract infections (UTIs) should be treated empirically with a short course of narrow-spectrum antibiotics. However, many clinicians order unnecessary tests and treat with long courses of antibiotics. The objective of this study was to understand how internists clinically approach UTIs. Methods 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 to 2019 to explore why clinical practices deviate from evidence-based guidelines. Interviews were transcribed, de-identified, and coded by two independent researchers using NVivo qualitative software. A Likert scale was used to evaluate preferences for possible interventions. Results Several common themes emerged. Both providers and residents ordered urine tests to “confirm” presence of urinary tract infections. Antibiotic prescriptions were often based on historical practice and anecdotal experience. Providers were more comfortable treating over the phone than residents and tended to prescribe longer courses of antibiotics. Both 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. Pragmatic clinical decision support tools were favored by providers, with residents preferring order sets and attendings preferring nurse triage algorithms. Conclusion Misconceptions regarding urinary tract infection management were common among residents and community primary care providers. Multifaceted interventions that include provider education, synthesis of guidelines, and pragmatic clinical decision support tools are needed to improve antibiotic prescribing and diagnostic testing; optimal interventions to improve UTI management may vary based on provider training level. Disclosures All authors: No reported disclosures.

Download Full-text