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Treating uncomplicated UTIs with narrower spectrum agents limits resistance
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Treating uncomplicated UTIs using narrower-spectrum agents appears to limit the development of antibiotic resistance locally, according to findings from a case-controlled analysis conducted over 7 years at a health care system in Colorado.
“In 2008, Denver Health changed its recommended treatment for uncomplicated UTI to nitrofurantoin and aligned its UTI stewardship program with Infectious Disease Society of America guidelines,” Patrick P. Ryan, MD, a physician at Denver Health and assistant professor of medicine and internal medicine at the University of Colorado School of Medicine, and colleagues wrote. “In this study, we provide a descriptive analysis of the changes in nitrofurantoin and levofloxacin prescribing and changes in [Escherichia coli] resistance with stewardship guideline changes.”
Ryan and colleagues analyzed ambulatory data from Denver Health to identify the number of nitrofurantoin and levofloxacin prescriptions per 1,000 outpatient prescriptions. They included ambulatory, nonpregnant female patients aged 18 to 89 years diagnosed with uncomplicated cystitis due to E. coli with an associated urine culture of more than 100,000 colony-forming units and excluded any case of UTI treated in the inpatient setting. According to the study, two control patients were matched at random with each case.
From January 2008 to December 2014, the researchers identified a total 2,104 E. coli UTIs, of which 1.9% of E. coli isolates demonstrated resistance to nitrofurantoin. Resistance remained stable at 2% over the study period, they reported.
Denver Health previously recommended trimethoprim-sulfamethoxazole (TMP-SMX) and levofloxacin to treat uncomplicated UTIs. For these agents, Ryan and colleagues reported observing an increase in resistance to levofloxacin from 13% to 15% during the study period, whereas resistance to TMP-SMX “remained relatively stable” at 26% to 28%.
Prescribing for nitrofurantoin also remained “relatively stable” during the study period, while prescriptions for levofloxacin and trimethoprim-sulfamethoxazole decreased.
Ryan and colleagues highlighted the presence of levofloxacin resistance as the most significant risk factor for nitrofurantoin resistance (OR = 2.72; 95% CI, 1.04-7.17).
“Further study should assess how frontline providers access antimicrobial stewardship guidelines and how often they adhere to guidelines,” Ryan and colleagues wrote. “Additional research should assess risk factors for nitrofurantoin resistance among a larger cohort of patients to increase the generalizability of the results and limit the risk of type II error.” – by Marley Ghizzone
Disclosures: The authors report no relevant financial disclosures.
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