National University Polyclinics, National University Health System, Singapore, Singapore.
Division of Family Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
Antimicrob Resist Infect Control. 2023 Aug 1;12(1):73. doi: 10.1186/s13756-023-01282-4.
Higher resistance rates of > 20% have been noted in Enterobacteriaceae urinary isolates towards ciprofloxacin and co-trimoxazole (C + C) in Singapore, compared with amoxicillin-clavulanate and nitrofurantoin (AC + N). This study examined if treatment failure varied between different antibiotics, given different resistant rates, for uncomplicated urinary tract infections (UTIs) managed in primary care. We also aimed to identify gaps for improvement in diagnosis, investigations, and management.
A retrospective cohort study was conducted from 2019 to 2021 on female patients aged 18-50 with uncomplicated UTIs at 6 primary care clinics in Singapore. ORENUC classification was used to exclude complicated UTIs. Patients with uncomplicated UTIs empirically treated with amoxicillin-clavulanate, nitrofurantoin, ciprofloxacin or co-trimoxazole were followed-up for 28 days. Treatment failure was defined as re-attendance for symptoms and antibiotic re-prescription, or hospitalisation for UTI complications. After 2:1 propensity score matching in each group, modified Poisson regression and Cox proportional hazard regression accounting for matched data were used to determine risk and time to treatment failure.
3194 of 4253 (75.1%) UTIs seen were uncomplicated, of which only 26% were diagnosed clinically. Urine cultures were conducted for 1094 (34.3%) uncomplicated UTIs, of which only 410 (37.5%) had bacterial growth. The most common organism found to cause uncomplicated UTIs was Escherichia coli (64.6%), with 92.6% and 99.4% of isolates sensitive to amoxicillin-clavulanate and nitrofurantoin respectively. Treatment failure occurred in 146 patients (4.57%). Among 1894 patients treated with AC + N matched to 947 patients treated with C + C, patients treated with C + C were 50% more likely to fail treatment (RR 1.49, 95% CI 1.10-2.01), with significantly higher risk of experiencing shorter time to failure (HR 1.61, 95% CI 1.12-2.33), compared to patients treated with AC + N.
Treatment failure rate was lower for antibiotics with lower reported resistance rates (AC + N). We recommend treating uncomplicated UTIs in Singapore with amoxicillin-clavulanate or nitrofurantoin, based on current local antibiograms. Diagnosis, investigations and management of UTIs remained sub-optimal. Future studies should be based on updating antibiograms, highlighting its importance in guideline development.
与阿莫西林-克拉维酸和呋喃妥因（AC + N）相比，新加坡肠杆菌科尿路感染分离株对环丙沙星和复方磺胺甲噁唑（C + C）的耐药率> 20%更高。本研究旨在检查在初级保健中管理的单纯性尿路感染（UTI）中，不同耐药率下不同抗生素的治疗失败是否存在差异。我们还旨在确定诊断、检查和管理方面的改进空间。
对 2019 年至 2021 年在新加坡 6 家初级保健诊所就诊的年龄在 18-50 岁的女性单纯性 UTI 患者进行了回顾性队列研究。ORENUC 分类用于排除复杂性 UTI。接受阿莫西林-克拉维酸、呋喃妥因、环丙沙星或复方磺胺甲噁唑经验性治疗的单纯性 UTI 患者接受了 28 天的随访。治疗失败定义为因症状再次就诊和抗生素再次处方，或因 UTI 并发症住院。在每组进行 2:1 倾向评分匹配后，使用修正泊松回归和 Cox 比例风险回归来确定风险和治疗失败时间。
4253 例 UTI 中，3194 例（75.1%）为单纯性，其中仅 26%经临床诊断。对 1094 例单纯性 UTI 进行了尿液培养，其中仅 410 例（37.5%）有细菌生长。引起单纯性 UTI 的最常见病原体是大肠埃希菌（64.6%），对阿莫西林-克拉维酸和呋喃妥因的敏感性分别为 92.6%和 99.4%。146 例患者（4.57%）发生治疗失败。在接受 AC + N 治疗的 1894 例患者与接受 C + C 治疗的 947 例患者中，接受 C + C 治疗的患者治疗失败的可能性增加了 50%（RR 1.49，95%CI 1.10-2.01），并且风险显著更高时间（HR 1.61，95%CI 1.12-2.33），与接受 AC + N 治疗的患者相比。
抗生素的治疗失败率较低，报告的耐药率较低（AC + N）。我们建议根据当前当地抗生素图，在新加坡用阿莫西林-克拉维酸或呋喃妥因治疗单纯性 UTI。UTI 的诊断、检查和管理仍然不理想。未来的研究应基于更新抗生素图，强调其在指南制定中的重要性。
