1421. Empiric Fluoroquinolone Prescribing Trends for Cystitis in Primary Care

Background Understanding outpatient antibiotic prescribing practices for urinary tract infections (UTIs) is vital in guiding future stewardship initiatives. Focusing on fluoroquinolones (FQs) is of value as FQs are commonly prescribed, but not recommended as first line therapy by the Infectious Diseases Society of America (IDSA) cystitis treatment guidelines and are also associated with multiple adverse effects. Boxed warnings state FQs should be reserved for patients with no alternative treatment options, due to risk of aortic dissection, C. difficile infection, antimicrobial resistance as well as tendon, joint, muscle, and nervous system damage. Methods This descriptive study assessed rates of guideline concordant empiric FQ prescribing from March 1 to June 30, 2019. Adult women prescribed an oral FQ for acute uncomplicated cystitis at a primary care clinic were included. Men, pregnant or breastfeeding women, and patients with pyelonephritis, urologic abnormality, or antibiotic use in the past 30 days were excluded. The primary outcome was the incidence of IDSA guideline concordance among FQs empirically prescribed. Guideline concordant empiric FQ therapy was defined as correct drug, dose, duration and frequency per IDSA guidelines when no first line drug is indicated due to allergy, adverse effect, previous treatment failure or most recent previous urine culture showing bacterial resistance. Secondary outcomes were mean dose (mg), mean duration (days) and incidence of adverse effects. Results Of 95 FQ prescriptions included, none met the primary outcome definition. Rates of guideline concordance for each component of the primary outcome definition were 6% for drug selection, 38% for dose, 37% for duration, and 99% for frequency. Mean daily doses exceeded guideline recommended doses by 62% and 100% for ciprofloxacin and levofloxacin, respectively. Mean duration was 5 days, 66% longer than 3 days as recommended by IDSA guidelines. Of 66 patients with documented follow up within 30 days, 3 (5%) experienced an adverse effect, and none developed C. difficile infection. Conclusion Current outpatient FQ prescribing for acute uncomplicated cystitis does not align with IDSA guidelines. Multifaceted antimicrobial stewardship initiatives are required to improve appropriate FQ use. Disclosures All Authors: No reported disclosures

General principles of uncomplicated cystitis therapy during pregnancy

Urinary tract infections during pregnancy are associated with severe complications. Earlier initiation of antibiotic treatment for acute uncomplicated cystitis, reduces the various complications.Objective. To assess the effectiveness of fosfomycin in the treatment of acute uncomplicated cystitis during II and III trimester of pregnancy.Material and methods. The study included 74 pregnant women who had acute uncomplicated cystitis in II or III trimesters. All patients received fosfomycin trometamol 3.754 g (equivalent to 3 g fosfomycin) as antimicrobial therapy for acute uncomplicated cystitis. The drug was prescribed to 24 pregnant women in the II, and 50 in the III trimester of pregnancy.Results. After treatment with fosfomycin signs of acute cystitis gone in all patients. At the same time, regression of clinical symptoms was noted during the next days after therapy in 95.9% (n = 71) of cases. Repeated microbiological test of the middle portion of urine was performed 7 days after the end of antibiotic therapy. In 94.6% (n = 70) cases, total elimination of the pathogen was achieved. In 5.4% (n = 4) cases, there was a significant decrease of colonization Follow-up for three months showed the absence of recurrence of acute cystitis in all pregnant women who were included in the study.Conclusion. Fosfomycin is a highly effective drug in the treatment of uncomplicated cystitis during pregnancy.

Uncomplicated urinary tract infection in the practice of a internist (clinical analysis)

Urinary tract infections remain one of the most common problems of modern medicine. In this regard, not only urologists, but also specialists of other specialties face urinary tract infection in their practice: internists, general practitioners, obstetricians and gynecologists. The growing resistance of uropathogs to antibiotics dictates the need for constant revision of the principles of antibacterial therapy of urinary tract infections. The article presents an analysis of two clinical cases: a sporadic episode of acute uncomplicated cystitis and an episode of recurrent urinary tract infection. The principles of modern diagnostics and therapeutic strategy are considered.

Urinary Microbiome Characteristics in Female Patients with Acute Uncomplicated Cystitis and Recurrent Cystitis

Traditionally, the diagnostic mainstay of recurrent urinary tract infection has been urinary culture. However, the causative uropathogen of recurrent cystitis has not been well established. Urine DNA next-generation sequencing (NGS) can provide additional information on these infections. Herein, we compared urine NGS results and urine cultures in patients with acute uncomplicated cystitis (AUC) and recurrent cystitis (RC), and evaluated the difference in microbiome patterns in the NGS results. Patients who underwent urine culture and NGS due to AUC or RC were retrospectively reviewed. All urine samples were collected via a transurethral catheter and studied utilizing a type of NGS called 16S ribosomal RNA gene amplification and sequencing. The sensitivity of urine NGS was significantly higher than that of conventional urine culture (69.0% vs. 16.7%, p < 0.05). The detection rate of urine NGS was slightly lower in the RC group than in the AUC group (67.7% vs. 72.7%). Microbiome diversity was significantly higher in the RC group compared to the AUC group (p = 0.007), and the microbiome composition was significantly different between the AUC and RC groups. In the urine NGS results, Pseudomonas, Acinetobacter, and Enterobacteriaceae were found in the AUC group, and Sphingomonas, Staphylococcus, Streptococcus, and Rothia spp. were detected in the RC group. Urine NGS can significantly increase the diagnostic sensitivity compared to traditional urine culture methods, especially in RC patients. AUC and RC patients had significant differences in bacterial diversity and patterns. Therefore, recurrent cystitis might be approached from a different perspective.

War and Peace: the difficult treatment of urinary tract infections and fosfomycin trometamol

The title of this review “War and peace” is not accidental and the analogies with a well-known literary masterpiece have absolutely justified ground. As in the case of Lev Tolstoy’s novel this title has a profound philosophical meaning, although at first glance it may seem quite obvious. The word «war» may well correspond to those hostile changes of microorganisms leading to the current problem of antimicrobial resistance recognized worldwide. This is the “war” we have to wage against the antibiotic-resistant bacteria today. And the «peace» in this context is considered as the world, the entire universe, all people, the whole society and its reaction to what is happening. On the other hand, the word «peace» means something opposite in meaning to the word «war». Thus, the essence of the title bears a sharp contrast between military actions and peacetime, between something that carries a threat to life and peace, or illness and recovery. Preserving original novel’s structure the authors of this review consistently consider justification of fosfomycin trometamol as a first-line drug in the treatment of acute uncomplicated cystitis in women taking into account the latest research, publications and global trends.

Systemic Inflammatory Response Syndrome Secondary to Nitrofurantoin

Nitrofurantoin is considered optimal treatment for acute uncomplicated cystitis by the Infectious Diseases Society of America and is being increasingly recommended due to microbial resistance to sulfamethoxazole/trimethoprim and various fluoroquinolone antibiotics. Adverse effects of nitrofurantoin are generally considered mild, with gastrointestinal complaints being the most common. However, there have been isolated case reports describing a more severe systemic inflammatory response syndrome–like reaction, which leads to diagnostic challenges and treatment complications. We report the case of a patient with repeat episodes of systemic inflammatory response syndrome secondary to nitrofurantoin, which was initially attributed to recurrent urinary tract infections.

Greek Version of the Acute Cystitis Symptom Score. Part I: Linguistic Validation

Objective: The Acute Cystitis Symptom Score (ACSS) was developed and validated as a self-reporting questionnaire for diagnosing and monitoring acute, uncomplicated cystitis (AC) in female patients. The study aims at the translation of the ACSS into Greek from original Russian as a source and American English as a new master version and at its linguistic validation. Material and Methods: Three independent professional native Greek translators, two of them experts in Russian and one in English, translated the ACSS from Russian and American English into Greek. The second group of three translators translated each of the three versions back into the original language to detect or correct any important discrepancies. These three Greek versions were then used for linguistic validation. Results: The English to Greek translation reflected more the spoken language, the two Russian to Greek translations more the written, formal language. A total of 60 randomly selected females and 30 healthcare professionals was asked about their preferences and to comment on each of the three translations. Considering all comments the scientific committee (SC) developed the Greek consensus version. For cognitive assessment additional 30 healthcare professionals and 30 females were asked to comment on the intelligibility of all items. Considering their comments the linguistically validated Greek study version was established by the SC. Conclusion: The linguistically validated Greek version of the ACSS can now be used for the clinical validation study.