Stanford, CA—While antibiotic prescribing is improving for uncomplicated urinary tract infections (UTIs), a high rate of guideline discordance continues, according to a new study.

UTIs are one of the most common bacterial infections in the United States, and clinical practice guidelines from the Infectious Diseases Society of America (IDSA) recommend nitrofurantoin, trimethoprim-sulfamethoxazole, and fosfomycin as first-line antibiotic treatments, and discourage the use of fluoroquinolone antibiotics, points out the report in the American Journal of Obstetrics & Gynecology.

In fact, the FDA has initiated several black box warnings about fluoroquinolones over the past decade due to antibiotic resistance and the potential for serious adverse events.

Stanford University School of Medicine authors recount that, historically, uncomplicated UTIs have high rates of guideline-discordant treatment, as demonstrated by past studies finding substantial use of fluoroquinolones, directly contradicting clinical-practice guidelines.

In light of that, the study team sought to assess the current concordance of physician prescribing practices with IDSA guidelines for the treatment of uncomplicated UTIs in women. Also identified were patient and physician predictors of guideline concordance.

The retrospective observational secondary analysis was conducted using a series of cross-sectional data extracted from the IQVIA National Disease and Therapeutic Index from 2015-2019, focusing on the estimated 44.9 million women with uncomplicated UTIs aged 18 to 75 years who were treated as outpatients.

Of the visits that resulted in antibiotic treatment, researchers determined an overall concordance rate of 58.4% (26.2 M visits/44.9 M visits); that 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, they note.

Results indicate that 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)
• Trimethoprim-sulfamethoxazole (26.3%, 11.8 M visits/44.9 M visits)
Fluoroquinolone prescriptions decreased from 2015 to 2019, while nitrofurantoin and beta-lactam use increased.

The authors calculate that, based on the logistic regression, patients aged 18 to 29 years (OR 1.60; 95% CI, 1.36-1.88, P <.001) and 30 to 44 years (OR 1.21; 95% CI, 1.03-1.42, P = .020) had a statistically significantly higher likelihood of receiving guideline-concordant treatment compared with patients aged 45 to 75 years.

They also point out that specific specialists—i.e., obstetricians/gynecologists (OR 3.56, 95% CI 2.91-4.37, P <.001) and urologists (OR 3.51, 95% CI 2.45-5.13, P <.001)—had a statistically significantly higher likelihood of concordant treatment compared with all other specialties combined.

“Guideline discordance continues in the treatment of uncomplicated urinary tract infections with the overuse of fluoroquinolones and the underuse of first-line antibiotics,” the researchers conclude. “Although improving, continued misuse of antibiotics may contribute to the growing rates of antibiotic resistance.”

The authors recommend actions such as educating physicians about antibiotic resistance and clinical practice guidelines and providing feedback on prescription habits. That could help increase guideline concordance and reduce the use of fluoroquinolones, especially for physicians in family and internal medicine, they emphasize.

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