Guidelines Often Overlooked in Treatment of Uncomplicated Cystitis

Kate Johnson

September 19, 2015

SAN DIEGO — When treating patients with uncomplicated urinary tract infection, primary care physicians often do not adhere to guidelines issued by the Infectious Diseases Society of America (IDSA), according to a new study.

"Low adherence to guidelines for the treatment of uncomplicated cystitis in primary care can lead to overuse of fluoroquinolones and excessive duration of treatment, both of which can cause higher antibiotic resistance," said Larissa Grigoryan, MD, from the Baylor College of Medicine in Houston.

This presents an opportunity for antibiotic stewardship, Dr Grigoryan said here at the Interscience Conference of Antimicrobial Agents and Chemotherapy 2015.

"Designing interventions to increase adherence to the guidelines will help preserve the antimicrobial efficacy of fluoroquinolones and reduce unnecessary days of antibiotic therapy," she told Medscape Medical News.

Of the three first-line treatments for uncomplicated urinary tract infection recommended in the IDSA guidelines (Clin Infect Dis. 2011;52:e103-120), trimethoprim and sulfamethoxazole for 3 days is preferable in areas where Escherichia coli resistance to this combination is less than 20%.

In areas where resistance is higher, nitrofurantoin for 5 days or a single dose of fosfomycin is recommended.

"Fluoroquinolones are considered alternative antimicrobials because of rising rates of resistance and collateral damage, which is a disturbance of microflora," Dr Grigoryan explained. "It is also recommended that fluoroquinolones be saved for more serious infections, both inside and outside the urinary tract."

But the researchers found that not only were fluoroquinolones most commonly prescribed, they were generally prescribed for longer than the recommended 3 days.

Study Details

Dr Grigoryan's team examined the prescribing of antibiotics from 2011 to 2014 for all uncomplicated urinary tract infections at two private family practice clinics in a large urban area. Most of the 1546 visits they assessed involved women who were young (mean age, 43.5 years), white (69%), and covered by private insurance (88%).

"We excluded women who had factors suggesting a complicated infection," Dr Grigoryan reported, such as pregnancy, genitourinary malignancy, three or more recurrences of urinary tract infection in the previous year, fever, and allergy to both nitrofurantoin and sulfa.

The fluoroquinolones ciprofloxacin and levofloxacin were the antibiotics most commonly prescribed, at 52%, followed by nitrofurantoin, at about 36%. However, there was a trend toward decreasing use of nitrofurantoin in each successive year of the study (P = .03).

The trimethoprim and sulfamethoxazole combination comprised about 12% of all prescriptions, and there was a trend toward increasing use over the study period (P = .02).

For the fluoroquinolones, 71% of all prescriptions were for longer than the recommended 3 days, 35% were for 5 days, and roughly 35% were for 7 to 10 days.

For trimethoprim and sulfamethoxazole, 82% of all prescriptions were for more than the recommended 3 days, and almost half were for more than 5 days.

For nitrofurantoin, 76% of all prescriptions were longer than the recommended 5 days, and about 70% were for 7 days.

 
It is clear that primary care providers have a strong preference for fluoroquinolones.
 

On multivariable regression analysis, older age and the presence of diabetes were independently associated with longer treatment. No patient or visit characteristics were associated with the specific choice of antibiotic.

"It is clear that primary care providers have a strong preference for fluoroquinolones and might be unaware of the evidence supporting a shorter duration for uncomplicated UTI than for many other infectious diseases," said Dr Grigoryan.

"Primary care physicians treat a wide spectrum of health problems, and the lack of adherence to guidelines may be due, in part, to the difficulty of keeping up with new recommendations for many different diseases," she told Medscape Medical News.

Low Adherence to Guidelines

These study results "are consistent with previous studies showing low adherence to guidelines" on urinary tract infection and other topics, said Kalpana Gupta, MD, MP, from the Veterans Affairs Boston Health Care System and Boston University School of Medicine, who was lead author of the IDSA guidelines.

"Longer durations of therapy and high rates of fluoroquinolone use are typical practice patterns that are potentially in conflict with guideline recommendations," she added.

"But we have to be careful about interpreting this as bad practice," she emphasized. "The nuances and caveats that might warrant longer therapy or use of broader-spectrum agents may not be captured by electronic chart review. And this is only one limited practice area of two private clinics."

"In general, though, improving dissemination of guideline recommendations through point-of-care education and other stewardship processes are important aspects of improving care," Dr Gupta noted. "This study highlights the fact that, at least in these two clinics, there is room for improvement."

Dr Grigoryan, her colleagues, and Dr Gupta have disclosed no relevant financial relationships.

Interscience Conference of Antimicrobial Agents and Chemotherapy (ICAAC) 2015). Presented September 18, 2015.

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