Abstract

BACKGROUND: Uncomplicated urinary tract infections are one of the most common bacterial infections in the United States. Clinical practice guidelines from the Infectious Diseases Society of America recommend nitrofurantoin, trimethoprim-sulfamethoxazole and fosfomycin as first-line antibiotic treatments, and discourage the use of fluoroquinolone antibiotics. The United States Food and Drug Administration released several black box warnings about fluoroquinolones over the past decade due to antibiotic resistance and a high burden of adverse events. Historically, uncomplicated urinary tract infections have high rates of guideline-discordant treatment with past studies noting substantial use of fluoroquinolones, directly contradicting clinical practice guidelines.OBJECTIVE: To assess the current concordance of physician prescribing practices with Infectious Diseases Society of America guidelines for the treatment of uncomplicated urinary tract infections in women and identify patient and physician predictors of guideline concordance.STUDY DESIGN: A retrospective observational secondary analysis was conducted using a series of cross-sectional data extracted from the IQVIA (Plymouth Meeting, PA) National Disease and Therapeutic Index from 2015-2019. An estimated 44.9 million women with uncomplicated urinary tract infections ages 18-75 years were treated as outpatients. This population was selected to lack relevant comorbidities or urological abnormalities so that it matched the Infectious Diseases Society of America guidelines. The proportion of prescriptions for each antibiotic drug class were reported with 95% confidence intervals and compared to the Infectious Diseases Society of America guidelines. Patient and physician characteristics were included in a multivariate logistic regression model to identify independent predictors of antibiotic selection and thereby guideline concordance.RESULTS: Of the visits that resulted in antibiotic treatment, the overall concordance rate was 58.4% (26.2 M visits/44.9 M visits) and increased from 48.2% (3.9 M visits/8.1 M visits) in 2015 to 64.6% (6.3 M visits/9.8 M visits) in 2019. The most commonly prescribed antibiotics were fluoroquinolones (36.4%, 16.3 M visits/44.9 M visits), nitrofurantoin (31.8%, 14.3 M visits/44.9 M visits) and trimethoprim-sulfamethoxazole (26.3%, 11.8 M visits/44.9 M visits). From 2015 to 2019 fluoroquinolone use decreased while nitrofurantoin and beta-lactam use increased. Based on the logistic regression, patients ages 18-29 years (OR 1.60, 95% CI 1.36-1.88, p<0.001) and 30-44 years (OR 1.21, 95% CI 1.03-1.42, p=0.020) had a statistically significantly higher likelihood of receiving guideline-concordant treatment compared to patients ages 45-75 years (reference group). Obstetricians/gynecologists (OR 3.56, 95% CI 2.91-4.37, p<0.001) and urologists (OR 3.51, 95% CI 2.45-5.13, p<0.001) had a statistically significantly higher likelihood of concordant treatment compared to all other specialties combined (reference group).CONCLUSION: Guideline discordance continues in the treatment of uncomplicated urinary tract infections with the overuse of fluoroquinolones and the underuse of first-line antibiotics. Although improving, continued misuse of antibiotics may contribute to the growing rates of antibiotic resistance. Actions such as educating physicians about antibiotic resistance and clinical practice guidelines, and providing feedback on prescription habits are needed to increase guideline concordance and therefore reduce the use of fluoroquinolones, especially for physicians in family and internal medicine.

View details for DOI 10.1016/j.ajog.2021.04.218

View details for PubMedID 33848538