Department of Medicine, Stanford University School of Medicine, Stanford, CA.
Department of Medicine, Stanford University School of Medicine, Stanford, CA.
Am J Obstet Gynecol. 2021 Sep;225(3):272.e1-272.e11. doi: 10.1016/j.ajog.2021.04.218. Epub 2021 Apr 20.
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 antibiotic agents. US Food and Drug Administration released several black box warnings about fluoroquinolones over the past decade owing 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.
This study aimed 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.
A retrospective observational secondary analysis was conducted using a series of cross-sectional data extracted from the IQVIA (Plymouth Meeting, Pennsylvania) National Disease and Therapeutic Index from 2015 to 2019. An estimated 44.9 million women with uncomplicated urinary tract infections at the age of 18 to 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 with 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.
Of the visits that resulted in antibiotic treatment, the overall concordance rate was 58.4% (26.2 million visits of 44.9 million visits) and increased from 48.2% (3.9 million visits of 8.1 million visits) in 2015 to 64.6% (6.3 million visits of 9.8 million visits) in 2019. The most commonly prescribed antibiotic agents were fluoroquinolones (36.4%, 16.3 million visits of 44.9 million visits), nitrofurantoin (31.8%, 14.3 million visits of 44.9 million visits), and trimethoprim-sulfamethoxazole (26.3%, 11.8 million visits of 44.9 million visits). From 2015 to 2019, fluoroquinolone use decreased whereas nitrofurantoin and beta-lactam use increased. Based on the logistic regression, patients aged 18 to 29 years (odds ratio, 1.60; 95% confidence interval, 1.36-1.88; P<.001) and 30 to 44 years (odds ratio, 1.21; 95% confidence interval, 1.03-1.42; P=.020) had a statistically significantly higher likelihood of receiving guideline-concordant treatment than patients aged 45 to 75 years (reference group). Obstetricians-gynecologists (odds ratio, 3.56; 95% confidence interval, 2.91-4.37; P<.001) and urologists (odds ratio, 3.51; 95% confidence interval, 2.45-5.13; P<.001) had a statistically significantly higher likelihood of concordant treatment than all other specialties combined (reference group).
Guideline discordance continues in the treatment of uncomplicated urinary tract infections with the overuse of fluoroquinolones and the underuse of first-line antibiotic agents. Although improving, continued misuse of antibiotic agents 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.
在美国，单纯性尿路感染是最常见的细菌性感染之一。美国传染病学会的临床实践指南推荐呋喃妥因、复方磺胺甲噁唑和磷霉素作为一线抗生素治疗药物，并劝阻使用氟喹诺酮类抗生素。由于抗生素耐药性和不良事件负担高，美国食品和药物管理局在过去十年发布了几项关于氟喹诺酮类药物的黑框警告。历史上，单纯性尿路感染的治疗方案与指南不符的情况很常见，过去的研究表明氟喹诺酮类药物的使用量很大，直接与临床实践指南相矛盾。
本研究旨在评估目前女性单纯性尿路感染治疗中医生处方实践与美国传染病学会指南的一致性，并确定医生和患者与指南一致的预测因素。
使用来自 2015 年至 2019 年 IQVIA（宾夕法尼亚州普利茅斯会议）国家疾病和治疗索引的一系列横断面数据进行回顾性观察性二次分析。估计有 4490 万 18 至 75 岁的女性患有单纯性尿路感染，作为门诊患者接受治疗。该人群选择没有相关合并症或泌尿系统异常，以符合美国传染病学会的指南。报告了每种抗生素药物类别的处方比例，置信区间为 95%，并与美国传染病学会的指南进行了比较。将患者和医生的特征纳入多变量逻辑回归模型，以确定抗生素选择的独立预测因素，从而确定与指南一致的因素。
在导致抗生素治疗的就诊中，总体一致性率为 58.4%（4490 万就诊中的 2620 万就诊），从 2015 年的 48.2%（810 万就诊中的 390 万就诊）增加到 2019 年的 64.6%（980 万就诊中的 630 万就诊）。最常开的抗生素药物是氟喹诺酮类药物（36.4%，4490 万就诊中的 1630 万就诊）、呋喃妥因（31.8%，4490 万就诊中的 1430 万就诊）和复方磺胺甲噁唑（26.3%，4490 万就诊中的 1180 万就诊）。从 2015 年到 2019 年，氟喹诺酮类药物的使用减少，而呋喃妥因和β-内酰胺类药物的使用增加。基于逻辑回归，年龄在 18 至 29 岁的患者（比值比，1.60；95%置信区间，1.36-1.88；P<.001）和 30 至 44 岁的患者（比值比，1.21；95%置信区间，1.03-1.42；P=.020）比 45 至 75 岁的患者（参考组）更有可能接受与指南一致的治疗。妇产科医生（比值比，3.56；95%置信区间，2.91-4.37；P<.001）和泌尿科医生（比值比，3.51；95%置信区间，2.45-5.13；P<.001）比所有其他专业的医生更有可能接受与指南一致的治疗（参考组）。
在单纯性尿路感染的治疗中，与指南不符的情况仍在继续，氟喹诺酮类药物的过度使用和一线抗生素药物的使用不足。尽管有所改善，但抗生素药物的滥用仍可能导致抗生素耐药性的不断增加。需要采取行动，如教育医生关于抗生素耐药性和临床实践指南，并提供处方习惯的反馈，以提高与指南的一致性，从而减少氟喹诺酮类药物的使用，特别是在家庭医学和内科医生中。
