Study examines appropriateness of antibiotic use for acute cystitis in adult females

Urinary tract infections (UTIs) are responsible for a significant percentage of outpatient antibiotic prescriptions for females. It is important to ensure the optimal choice of drug,dose and duration of therapy to help reduce future bacterial resistance and the likelihood of adverse events and/or UTI recurrence. A study in British Columbia is the first in Canada to examine the quality of antibiotic prescribing (drug, dose and duration) for females with uncomplicated UTI (cystitis) in the outpatient setting. The investigators included all adult female residents of British Columbia with a physician record for cystitis from 2014–2018. The study excluded females with a history of urologic abnormalities, spinal cord injury, catheter use or kidney transplant, as well as pregnant females. Prescriptions were classified as either appropriate or inappropriate, based on first-line agent, dose and duration parameters. Appropriate prescribing included prescriptions fully guideline concordant by agent, dose and duration (i.e., guideline adherent), and/or the use of non-first-line agents when clinically justified (i.e., clinically appropriate). Inappropriate prescribing included prescriptions concordant by agent, but discordant by dose or duration (i.e., effective but unnecessary or undertreatment), as well as the use of non-first-line antibiotics when not clinically justified (i.e., not recommended). In the absence of renal impairment (creatinine clearance > 40 mL/min), appropriate first-line treatments for cystitis were nitrofurantoin (100 mg twice daily × 5 d) or trimethoprim-sulfamethoxazole (TMP/SMX; 160/800 mg twice daily × 3 d). In the presence of renal impairment (creatinine clearance < 40 mL/min), appropriate first-line treatments were fosfomycin (3 g daily × 1 d) or TMP/SMX (160/800 mg twice daily × 3 d). Quinolones are not recommended as first-line treatment for uncomplicated cystitis due to the risks for antimicrobial resistance conferred by their routine use, as well as increased risk for Clostridioides difficile. Results showed the following:The researchers examined 182,162 episodes of cystitis, with 70% receiving an antibiotic prescription. Overall, only 35% of prescriptions were considered appropriate. In patients with chronic kidney disease, 62% of prescriptions were fully appropriate.Inappropriate antibiotic use accounted for two-thirds of cystitis-associated prescribing for adult females (453 prescriptions per 1,000 episodes). Of these prescriptions, 44% were effective but unnecessary, 20% were not recommended and 2% were categorized as undertreatment.The majority of effective but unnecessary prescriptions (99%) involved excess duration of therapy.Antibiotics categorized as not recommended (not clinically justified) primarily involved ciprofloxacin (67%), fosfomycin (16%) and cefixime (6%).Nitrofurantoin and trimethoprim-sulfamethoxazole, accounted for 71% of total antibiotic use.Nitrofurantoin was most commonly dispensed for seven days, followed by five days, then 10. Seven days was also most common for TMP/SMX, followed by five days, then three days. All fosfomycin prescriptions were for one day. The researchers concluded that in this study, the use of first-line antimicrobial agents and duration of therapy were often not consistent with guideline recommendations. Antibiotic stewardship efforts should focus on prescribing first-line, narrow-spectrum agents and shortening the duration of therapy from seven days to three to five days, in line with clinical guidelines. ReferenceSaatchi A, Silverman M, Shariff SZ, et al. Quality of antibiotic prescribing for outpatient cystitis in adult females. JAMMI Canada;2024;9(2);61-72. (accessed August 6, 2024).

Study examines appropriateness of antibiotic use for acute cystitis in adult females

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