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Prior cultures predict subsequent susceptibility in patients with recurrent urinary tract infections
- Marissa Valentine-King, Barbara Trautner, Roger Zoorob, George Germanos, Jason Salemi, Kalpana Gupta, Larissa Grigoryan
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- Journal:
- Antimicrobial Stewardship & Healthcare Epidemiology / Volume 2 / Issue S1 / July 2022
- Published online by Cambridge University Press:
- 16 May 2022, p. s67
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Background: Patients with recurrent urinary tract infections (rUTI) experience frequent exposure to antimicrobial regimens, leaving them at higher risk for developing antibiotic resistance. Little information on the prevalence of antibiotic resistance among patients with rUTI has been published. Although the IDSA recommends using a prior culture to guide empiric treatment, studies have not examined the predictive ability of a prior culture among patients meeting rUTI criteria. We constructed an antibiogram and evaluated test metrics, including sensitivity, specificity, and positive predictive value (PPV) and negative predictive values (NPV) of a prior culture (any organism), on predicting resistance (PPV) or susceptibility (NPV) of a future culture among patients with uncomplicated rUTI in an outpatient setting. Methods: We retrospectively extracted electronic health record data from outpatients aged ≥18 years who had an ICD-10 code for cystitis listed twice in 6 months or thrice in 12 months between November 1, 2016, and December 31, 2018. Patients sought care at either urology or primary care practices within an academic medical center in Houston, Texas. Patients with functional or structural abnormalities of the genitourinary tract, signs or symptoms of pyelonephritis, or pregnancy were excluded. Antibiogram data were reported for uropathogens with ≥30 isolates, and intermediate results were considered resistant. Test metrics and Bayes’ PPV and NPV were calculated using standard formulas. Results: We included 597 visits from 232 unique patients. Most were White (63%) and female (92%), and the cohort had a median age of 58 (IQR, 41–68). Among 310 rUTI episodes with a urine culture, 189 (61%) had at least 1 uropathogen isolated, and Escherichia coli (n = 130, 66%) was most common among all 196 uropathogens. E. coli isolates had >20% resistance to 10 of 18 antibiotics (Fig. 1). E. coli resistance to ciprofloxacin was 27.9%, resistance to nitrofurantoin was 5.5%, and resistance to trimethoprim-sulfamethoxazole was 38.0%. The PPVs for predicting resistance were highest for ceftriaxone (0.86; 95% CI, 0.60–0.96), ciprofloxacin (0.84; 95% CI, 0.63–0.94), and levofloxacin (0.84; 95% CI, 0.63–0.94). NPVs of resistance were highest for gentamicin (0.97; 95% CI, 0.83–1.00), ceftriaxone (0.94; 95% CI, 0.86–0.98), and cefepime (0.94; 95% CI, 0.84–0.98), whereas NPVs for cefuroxime, ciprofloxacin, levofloxacin, and nitrofurantoin were all >0.83. Conclusions: We detected considerable antibiotic resistance among patients with rUTI to commonly prescribed antibiotics. Prior urine culture susceptibility demonstrated moderate-to-high PPVs for predicting future resistance to ceftriaxone and fluoroquinolones as well as high NPVs for several cephalosporins and fluoroquinolones, which could inform empiric prescribing choices.
Funding: This investigator-initiated research study was funded by Rebiotix, a Ferring Company.
Disclosures: None
Analysis of recurrent urinary tract infection management in women seen in outpatient settings reveals opportunities for antibiotic stewardship interventions
- Marissa A. Valentine-King, Barbara W. Trautner, Roger J. Zoorob, George Germanos, Michael Hansen, Jason L. Salemi, Kalpana Gupta, Larissa Grigoryan
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- Journal:
- Antimicrobial Stewardship & Healthcare Epidemiology / Volume 2 / Issue 1 / 2022
- Published online by Cambridge University Press:
- 17 January 2022, e8
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Objectives:
We characterized antibiotic prescribing patterns and management practices among recurrent urinary tract infection (rUTI) patients, and we identified factors associated with lack of guideline adherence to antibiotic choice, duration of treatment, and urine cultures obtained. We hypothesized that prior resistance to nitrofurantoin or trimethoprim–sulfamethoxazole (TMP-SMX), shorter intervals between rUTIs, and more frequent rUTIs would be associated with fluoroquinolone or β-lactam prescribing, or longer duration of therapy.
Methods:This study was a retrospective database study of adult women with International Classification of Diseases, Tenth Revision (ICD-10) cystitis codes meeting American Urological Association rUTI criteria at outpatient clinics within our academic medical center between 2016 and 2018. We excluded patients with ICD-10 codes indicative of complicated UTI or pyelonephritis. Generalized estimating equations were used for risk-factor analysis.
Results:Among 214 patients with 566 visits, 61.5% of prescriptions comprised first-line agents of nitrofurantoin (39.7%) and TMP-SMX (21.5%), followed by second-line choices of fluoroquinolones (27.2%) and β-lactams (11%). Most fluoroquinolone prescriptions (86.7%), TMP-SMX prescriptions (72.2%), and nitrofurantoin prescriptions (60.2%) exceeded the guideline-recommended duration. Approximately half of visits lacked a urine culture. Receiving care through urology via telephone was associated with receiving a β-lactam (adjusted odds ratio [aOR], 6.34; 95% confidence interval [CI], 2.58–15.56) or fluoroquinolone (OR, 2.28; 95% CI, 1.07–4.86). Having >2 rUTIs during the study period and seeking care from a urology practice (RR, 1.28, 95% CI, 1.15–1.44) were associated with longer antibiotic duration.
Conclusions:We found low guideline concordance for antibiotic choice, duration of therapy and cultures obtained among rUTI patients. These factors represent new targets for outpatient antibiotic stewardship interventions.
Analysis of Recurrent Urinary Tract Infection Management in Outpatient Settings Reveals Opportunities for Antibiotic Stewards
- Marissa Valentine-King, Barbara Trautner, Roger Zoorob, George Germanos, Jason Salemi, Kalpana Gupta, Larissa Grigoryan
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- Journal:
- Antimicrobial Stewardship & Healthcare Epidemiology / Volume 1 / Issue S1 / July 2021
- Published online by Cambridge University Press:
- 29 July 2021, p. s34
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Background: Studies of antibiotic prescribing choice and duration have typically excluded women with recurrent UTI (rUTI), yet the Infectious Disease Society of America (IDSA) UTI treatment guidelines are applicable to recurrent and sporadic cystitis. We sought to better understand prescribing practices among uncomplicated rUTI patients in terms of choice of drug, duration of therapy, and the risk factors for receiving guideline-discordant therapy. Methods: We performed a retrospective database study by extracting electronic health record data from adults seen at academic primary care, internal medicine, or urology practices between November 2016 and December 2018. Inclusion criteria included having ≥2 or ≥3 International Classification of Diseases Tenth Edition (ICD-10) cystitis codes recorded within a 6- or 12-month period, respectively. We excluded patients with ICD-10 codes indicating any structural or functional genitourinary comorbidities, interstitial cystitis, vaginosis, compromised immune systems, or pregnancy in the prior year. Patients were also excluded if they had signs or symptoms of pyelonephritis at presentation. Results: Overall, 232 patients presented for 597 outpatient visits. Most were married (52.2%), non-Hispanic white (62.9%), and female (92.2%), with a median age of 58 years (IQR, 41–68). Only 21% of visits with an antibiotic prescribed for treatment consisted of a first-line therapy agent prescribed for the recommended duration. In terms of antibiotic choice, these agents were prescribed in 58.4% of scenarios, which primarily included nitrofurantoin (37.8%) and trimethoprim-sulfamethoxazole (TMP-SMX) (20.3%). Guideline-discordant choices of fluoroquinolones (28.8%), and β-lactams (11.2%) were the second and third most commonly prescribed drug categories, respectively. Multinomial logistic regression identified age (OR, 1.02; 95% CI, 1.002–1.04) or having a telephone visit (OR, 3.17; 95% CI, 1.54–6.52) as independent risk factors for receiving a β-lactam. The duration exceeded the 3-day guideline recommendation in 87.6% of fluoroquinolones and 73% of TMP-SMX (73%) prescriptions, and 61% of nitrofurantoin prescriptions exceeded the recommended 5-day duration. Multiple logistic regression analysis revealed that seeking care at a urology clinic (OR, 2.81; 95% CI, 1.59–5.17) served as an independent factor for therapy duration exceeding guideline recommendations. Conclusions: This retrospective study revealed shortcomings in prescribing practices in the type and duration of therapy for rUTI. rUTI as well as sporadic UTI are important targets for outpatient antibiotic stewardship interventions.
Funding: This investigator-initiated research study was funded by Rebiotix Inc, a Ferring Company.
Disclosures: None