Inadequate adherence to Swedish guidelines for uncomplicated lower urinary tract infections among adults in general practice

Antibiotic use during pregnancy in Sweden: A nationwide utilization study covering 2007-2019

INTRODUCTION

Antibiotics are often prescribed during pregnancy. Assessing the current state of prenatal antibiotic use is therefore imperative for optimizing prescribing and identifying emerging research priorities. The study aimed to describe recent trends and patterns in antibiotic use during pregnancy among women who gave birth in Sweden, including user characteristics.

MATERIAL AND METHODS

Population-based descriptive study using linked nationwide registers. All pregnancies delivered in Sweden from 2007 to 2019 were included. Prevalence of use was defined as the percentage of pregnancies during which at least one prescription forantibiotics was filled. Temporal trends in the prevalence of antibiotic use by calendar year, trimester and weeks of gestation were assessed from time series graphs.

RESULTS

Prescriptions for systemic antibiotics were filled in 20.7% of 1 434 431 pregnancies overall, decreasing from 24.7% in 2007 to 18.0% in 2019. Phenoxymethylpenicillin (8.5%), pivmecillinam (6.5%), nitrofurantoin (4.7%), amoxicillin (1.6%) and cefadroxil (1.5%) use were the most prevalent. Their use decreased over the 13-year period, except for pivmecillinam, which increased from 4.0% to 7.4%. Prevalence of use was highest in the second trimester (9.5%), with weekly trends peaking at 13 and 34 weeks of gestation. Compared with non-users, antibiotic users more often belonged to the youngest and oldest age strata, carried multipleton pregnancies, had delivered before, had attained a lower education level and smoked in early pregnancy. A higher body mass index, asthma, chronic renal disease and diabetes mellitus were more prevalent among antibiotic users than among non-users.

CONCLUSIONS

Although outpatient antibiotic use during pregnancy in Sweden has been declining, one in five pregnancies was exposed to systemic antibiotics.

Increased demand of urine cultures from Danish general practice: a five-year register-based study

OBJECTIVE

To characterise and explore the development in the number and content of urine samples sent from general practice in the North Denmark Region to the Department of Clinical Microbiology (DCM) at Aalborg University Hospital during a five-year period.

DESIGN

A register-based study.

SETTING

General practice.

SUBJECTS

Urine samples received at DCM, Aalborg University Hospital from general practice between 2017 and 2022.

MAIN OUTCOME MEASURES

Number and content of urine samples.

RESULTS

A total of 255,271 urine samples from general practice were received at DCM, with 76.1% being from female patients. Uropathogens were identified in 43.0% of the samples. During the five-year period, a 23.0% increase in the number of urine samples per person (incidence rate ratio (IRR) 1.23, 95% CI 1.21-1.25) was observed. A slight increase in the proportion of positive cultures (risk ratio (RR) 1.03, 95% CI 1.01-1.05) was seen. No notable change in the patient population (age, gender) was observed. Overall, Escherichia coli was the most identified uropathogen (60.4%) followed by Klebsiella spp. (8.7%) and Enterococcus spp. (7.7%). Distribution of the various uropathogens differed slightly depending on patient gender and age, importantly E. coli was less frequently observed in males aged >65 years.

CONCLUSION

During the past five years an increasing amount of urine cultures have been requested at DCM from general practice. Importantly, the cause(s) of this increasing demand needs to be explored further in future studies.

Descriptive management of suspected acute cystitis in adult patients by French general practitioners during remote consultation

OBJECTIVES

The main objective of this study was to analyze French general practitioners' (GP) online prescriptions for suspected acute cystitis using a single nationwide teleconsultation platform.

PATIENTS AND METHODS

First, a descriptive study of management for suspected cystitis was conducted from the 1^st of January to the 31^st of December 2020. After which, following pedagogical intervention, a pre/post descriptive analysis of the antibiotics prescribed was carried out.

RESULTS

Some 496,041 teleconsultations (TCs) were carried out in 2020 on the Qare platform. Among them, 15089 TCs for cystitis with ICD-10 encoding (N30) were analyzed. Fosfomycin trometamol was the most prescribed antibiotic (n=10297, 69%), while fluoroquinolones (n=1568, 10.6%) were the second. Urine test strip was prescribed in 3157 (20%) and urine culture in 7033 (47%) of the TCs. July-August 2020 and July-August 2021 were compared and while a significant drop in fluoroquinolone prescriptions and a major increase in Fosfomycin trometamol were observed, there was no change in the prescriptions of urine culture. An average antibiotic conformity rate of 61.5% was observed before the intervention, and 68.8% afterwards.

CONCLUSIONS

Cystitis is a recurrent reason for remote consultation. The study demonstrated sizable over-prescription of urine culture, ultrasound, and fluoroquinolones. Intervention should be improved and strengthened to guarantee continuous training and awareness of GP's on appropriate cystitis prescriptions in telemedicine.

Fluoroquinolones and Other Antibiotics Redeemed for Cystitis—A Swedish Nationwide Cohort Follow-Up Study (2006–2018)

Background: Antibiotics are commonly prescribed for outpatient management of cystitis. Previous evidence suggests that certain factors likely beyond the infection seem to influence the choice of antimicrobial treatment. However, studies on the specific antibiotic treatments for cystitis are lacking. This study aimed to explore the antibiotic treatments for cystitis using nationwide primary healthcare data and investigate if factors beyond the infection could be associated with fluoroquinolone treatment. Methods: This nationwide follow-up cohort study consisted of 352,507 women with cystitis. The primary aim was to investigate what specific classes of antibiotics were redeemed by patients within five days from the cystitis diagnosis. Each patient could only be included once. Logistic regression models were also used to examine the relationship between fluoroquinolone (FQ) treatment, parity, and sociodemographic factors. Results: In total, 192,065 antibiotic prescriptions were redeemed. Pivmecillinam (58.4%) followed by nitrofurantoin (22.2%), trimethoprim (12.0%), fluoroquinolone (5.6%), and cephalosporins (1.5%) were the most redeemed antibiotics. Sociodemographic factors were weakly associated with fluoroquinolone treatment; young age was inversely associated with fluoroquinolone treatment. Parity and cervical cancer history were not associated with fluoroquinolone treatment. The proportion of fluoroquinolone and trimethoprim treatments decreased over time, while pivmecillinam and nitrofurantoin increased. Conclusions: The treatment trends of antibiotics redeemed within five days from a cystitis diagnosis were similar to the national surveillance program of these antibiotics (not diagnosis linked). Fluoroquinolones were weakly associated with sociodemographic factors, which likely is only of historical relevance.

The Five Ds of Outpatient Antibiotic Stewardship for Urinary Tract Infections

Urinary tract infections (UTI) are one of the most common indications for antibiotic prescriptions in the outpatient setting. Given rising rates of antibiotic resistance among uropathogens, antibiotic stewardship is critically needed to improve outpatient antibiotic use, including in outpatient clinics (primary care and specialty clinics) and emergency departments. Outpatient clinics are in general a neglected practice area in antibiotic stewardship programs, yet most antibiotic use in the United States is in the outpatient setting. This article provides a comprehensive review of antibiotic stewardship strategies for outpatient UTI in the adult population, with a focus on the "five Ds" of stewardship for UTI, including right diagnosis, right drug, right dose, right duration, and de-escalation. Stewardship interventions that have shown success for improving prescribing for outpatient UTI are discussed, including diagnostic stewardship strategies, such as reflex urine cultures, computerized decision support systems, and modified reporting of urine culture results. Among the many challenges to achieving stewardship for UTI in the outpatient setting, some of the most important are diagnostic uncertainty, increasing antibiotic resistance, limitations of guidelines, and time constraints of stewardship personnel and front-line providers. This article presents a stewardship framework, built on current evidence and expert opinion, that clinicians can use to guide their own outpatient management of UTI.

The Effect of Sociodemographic Factors, Parity and Cervical Cancer on Antibiotic Treatment for Uncomplicated Cystitis in Women: A Nationwide Cohort Study

BACKGROUND

Uncomplicated cystitis is one of the most common reasons for antibiotic treatment in otherwise healthy women. Nationwide studies on antibiotic treatment for this infection and in relation to factors beyond the infection itself have hitherto not been available.

METHODS

This was a nationwide open cohort study consisting of 352,507 women aged 15-50 years with uncomplicated cystitis (2006-2018). The outcome was a redeemed antibiotic prescription within five days from the cystitis diagnosis. Logistic regression models were used to examine the relationship between the outcome and the predictor variables.

RESULTS

This study identified 192,065 redeemed treatments (54.5%). Several sociodemographic variables were associated with antibiotic treatment. For example, women with the lowest income had an odds ratio (OR) of 1.26 (95% CI 1.23-1.28) compared to those with the highest income. History of cervical cancer and high parity were also associated with lower treatment rates.

CONCLUSION

This study presents novel factors beyond the infection which seem to affect the antibiotic treatment for uncomplicated cystitis in women. Future studies to investigate possible mechanisms are warranted in order to properly use our findings. This may help healthcare workers and planners to provide a more equal treatment plan for this common infection, which may reduce misuse of antibiotics, decrease costs and improve efforts against antibiotic resistance.

Sociodemographic factors and uncomplicated cystitis in women aged 15-50 years: a nationwide Swedish cohort registry study (1997-2018)

Background

Symptoms suggestive of uncomplicated cystitis constitutes one of the most common reasons to seek health care in otherwise healthy women. Previous studies regarding the relationship between sociodemographic factors and uncomplicated cystitis are limited, mainly because of the lack of nationwide population-based data from primary healthcare settings, where most uncomplicated cystitis are diagnosed.

Methods

A Swedish nation-wide open cohort study consisting of 2 044 065 females who were 15–50 years of age during the study period (1997–2018) was conducted. The outcome was first event uncomplicated cystitis diagnosed in primary health care rather than an assessment of the "true" incidence, which is not feasible in nationwide datasets. Cox regression models were used in the statistical analyses.

Findings

The study identified 546 076 first events of uncomplicated cystitis (26•7% of the study population), corresponding to an incidence rate per 100 person-years of 2•91 (95% CI 2•90–2•91). In fully adjusted models, rural living was associated with lower risks of uncomplicated cystitis (Hazard ratio, HR, 0•67; 95% CI, 0•66–0•68) compared to urban living, while both Middle Eastern/North African (HR, 1•15; 95% CI, 1•14–1•16) and Latin American/Caribbean (HR, 1•24; 95% CI, 1•22–1•27) women had higher risks compared to Swedish women. Low education and low income were also associated with higher risks compared to high education and high income.

Interpretation

This study presents novel risk factors associated with uncomplicated cystitis in women. The findings may help health care workers in the treatment of women with symptoms of uncomplicated cystitis.

Funding

The Primary Healthcare Management and ALF funding (Region Skåne, Sweden) and the Swedish Research Council.

Surgical Outcomes Following Gender Affirming Penile Reconstruction: Patient-Reported Outcomes From a Multi-Center, International Survey of 129 Transmasculine Patients

BACKGROUND

Current literature on surgical outcomes after gender affirming genital surgery is limited by small sample sizes from single-center studies.

AIM

To use a community-based participatory research model to survey a large, heterogeneous cohort of transmasculine patients on phalloplasty and metoidioplasty outcomes.

METHODS

A peer-informed survey of transmasculine peoples' experience was constructed and administered between January and April 2020. Data collected included demographics, genital surgery history, pre- and postoperative genital sensation and function, and genital self-image.

OUTCOMES

Of the 1,212 patients completing the survey, 129 patients underwent genital reconstruction surgery. Seventy-nine patients (61 percent) underwent phalloplasty only, 32 patients (25 percent) underwent metoidioplasty only, and 18 patients (14 percent) underwent metoidioplasty followed by phalloplasty.

RESULTS

Patients reported 281 complications requiring 142 revisions. The most common complications were urethrocutaneous fistula (n = 51, 40 percent), urethral stricture (n = 41, 32 percent), and worsened mental health (n = 25, 19 percent). The average erect neophallus after phalloplasty was 14.1 cm long vs 5.5 cm after metoidioplasty (P < .00001). Metoidioplasty patients report 4.8 out of 5 erogenous sensation, compared to 3.4 out of 5 for phalloplasty patients (P < .00001). Patients who underwent clitoris burial in addition to primary phalloplasty did not report change in erogenous sensation relative to primary phalloplasty patients without clitoris burial (P = .105). The average postoperative patient genital self-image score was 20.29 compared with 13.04 for preoperative patients (P < .00001) and 21.97 for a historical control of cisgender men (P = .0004).

CLINICAL IMPLICATIONS

These results support anecdotal reports that complication rates following gender affirming genital reconstruction are higher than are commonly reported in the surgical literature. Patients undergoing clitoris burial in addition to primary phalloplasty did not report a change in erogenous sensation relative to those patients not undergoing clitoris burial. Postoperative patients report improved genital self-image relative to their preoperative counterparts, although self-image scores remain lower than cisgender males.

STRENGTHS & LIMITATIONS

These results are unique in that they are sourced from a large, heterogeneous group of transgender patients spanning 3 continents and dozens of surgical centers. The design of this study, following a community-based participatory research model, emphasizes patient-reported outcomes with focus on results most important to patients. Limitations include the recall and selection bias inherent to online surveys, and the inability to verify clinical data reported through the web-based questionnaire.

CONCLUSION

Complication rates, including urethral compromise and worsened mental health, remain high for gender affirming penile reconstruction. Robinson IS, Blasdel G, Cohen O, et al. Surgical Outcomes Following Gender Affirming Penile Reconstruction: Patient-Reported Outcomes From a Multi-Center, International Survey of 129 Transmasculine Patients. J Sex Med 2021;18:800-811.

Workload, diagnostic work-up and treatment of urinary tract infections in adults during out-of-hours primary care: a retrospective cohort study

Background

Urinary tract infections (UTIs) are one of the most common infections in primary care. Previous research showed that GPs find it challenging to diagnose UTIs and frequently divert from guidelines leading to unwarranted antibiotic prescriptions and inefficient use of diagnostics such as urinary cultures. We hypothesise that management of UTIs during out-of-hours care may be extra challenging due to a higher workload and logistical issues regarding diagnostic work-up and obtaining results. We therefore aimed to study the workload, diagnostic work-up and treatment of UTIs during out-of-hours primary care.

Methods

We performed a retrospective observational cohort study in which we analysed a full year (2018) of electronic patient records of two large Dutch GP out-of-hours centres. All adult patients with UTI symptoms were included in this study. Descriptive statistics and multivariate regression were used to analyse diagnostics and subsequent management.

Results

A total of 5657 patients were included (78.9% female, mean age of 54 years), with an average of eight patients per day that contact a GP out-of-hours centre because of UTI symptoms. Urinary dipsticks were used in 87.5% of all patients visiting the out-of-hours centres with UTI symptoms. Strikingly, urinary cultures were only requested in 10.3% of patients in which urinary culture was indicated. Seventy-four percent of the patients received antibiotics. Seventy-nine percent of the patients with a negative nitrite test still received antibiotics. Remarkably, patients at risk of complications because of a UTI, such as men, received fewer antibiotic prescriptions.

Conclusions

In total, 74% of the patients received antibiotics. 8 out of 10 patients still received an antibiotic prescription in case of a negative nitrite test, and 9 out of 10 patients with an indication did not receive a urine culture. In conclusion, we found that correctly diagnosing UTIs and prescribing antibiotics for UTIs is a challenge that needs major improvement, especially during out-of-hours GP care.

Management of urinary tract infections: what do doctors recommend and patients do? An observational study in German primary care

Background

Uncomplicated urinary tract infections (UTIs) in women are usually managed in primary care with antibiotics. However, many women seem to prefer to handle UTI symptoms with nonsteroidal anti-inflammatory drugs (NSAIDs) and other remedies. The aim of this study was to compare UTI management as recommended by physicians with the patients’ management at home.

Methods

This prospective cohort study in German primary care is based on clinical data from local practices and patient questionnaires. Participating women completed a baseline data sheet in the practice; their urine sample was tested by a dipstick in the practice and cultured by a laboratory. The women reported treatment and symptom-related impairment on an eight-item symptom questionnaire daily for 7 days. Using growth curve models, we analysed the influence of time on the total severity score to examine how symptoms changed across days. We then examined whether symptom severity and symptom course differed between patients who took antibiotics or NSAIDs.

Results

A total of 120 women (mean age of 43.3 ± 16.6 years) were enrolled. The urine dipstick was positive for leucocytes in 92%, erythrocytes in 87%, and nitrites in 23%. Physicians prescribed antibiotics for 102 (87%) women and recommended NSAIDs in 14 cases. According to the women’s reports, only 60% (72/120) took antibiotics, while the remainder took NSAIDs and other remedies. Symptoms declined from day 0 to day 6, irrespective of whether women decided to take an antibiotic, NSAIDs, none or both, as confirmed by a significant curvilinear time effect (B = 0.06, SE = 0.005, p < .001). The symptom course, however, was moderated by taking antibiotics so that the change in symptom severity was somewhat more pronounced in women taking antibiotics (B = 0.06) than in the remainder (B = 0.04).

Conclusion

A substantial proportion of women did not follow their physicians’ treatment recommendations, and many used NSAIDs. All women had a good chance of recovery irrespective of whether they decided to take antibiotics. A sensitive listening to patient preferences in the consultation may encourage physicians to recommend and prescribe symptomatic treatment with NSAID more often than antibiotic medicines.

Uncomplicated urinary tract infections in Swedish primary care; etiology, resistance and treatment

Background

Uncomplicated urinary tract infection (uUTI) is common and a majority of patients are prescribed antibiotics. There is little knowledge about antibiotic resistance in urine samples from patients with uUTI in primary health care (PHC).

The aim was to describe antibiotic treatment, bacterial findings, the prevalence of resistant E.coli and factors associated with antibiotic resistance. The aim was also to compare the prevalence of resistant E.coli in clinical practice with the prevalence of resistant E.coli in routine microbiological laboratory data.

Methods

This observational study in PHC setting started in November 2014 and ended in March 2016. Women aged 17 years and older with symptoms indicating uUTI from eight PHCs were included. Questionnaires were used to retrieve anamnestic data. All urine samples were sent to the local laboratory of microbiology for diagnostic analysis and susceptibility testing. Proportions of resistant E.coli were compared with corresponding data from the regional laboratory.

Results

Urine cultures were analysed in 304 women with a median age of 46 (IQR 32–66) years. Bacterial growth was found in 243 (80%) of urine samples, and E.coli in 72% of the positive samples. A total of 80% of detected E.coli isolates were susceptible to all tested antimicrobials and resistance rates to ciprofloxacin were lower than reported from the local clinical laboratory. Antibiotic treatment within the last year was independently associated with antibiotic resistant E.coli in the urine sample adjusted OR 4.97 (95% CI 2.04–12.06). A total of 74% of the women were treated with antibiotics. The most prescribed was pivmecillinam followed by nitrofurantoin.

Conclusions

Antibiotic resistance in E.coli was low. Antibiotic treatment within the last year was associated with antibiotic resistant E.coli. Data from the clinical microbiology laboratory indicates that laboratory data may overestimate antibiotic resistance and lead to an unnecessary change in empiric antibiotic treatment of uUTI in primary care. The empirically prescribed antibiotics, were inline with Swedish treatment recommendations for uUTI.

Antibiotic-Resistant E. coli in Uncomplicated Community-Acquired Urinary Tract Infection

BACKGROUND

Routine urine culture testing is not recommended for uncomplicated urinary tract infections (UTIs). As a result, the antibiotic resistance patterns or the organisms causing UTIs are not adequately reflected in routine data. We studied the sensitivity of Escherichia coli (E. coli) to trimethoprim (TMP) and to cotrimoxazole (i.e., trimethoprim/sulfamethoxazole, TMP/SMX) in community-acquired UTI and compared the findings with the resistance data of the Antimicrobial Resistance Surveillance System (ARS).

METHODS

General practitioners and internists in private practice prospectively recruited all of their adult patients with symptoms of a urinary tract infection from May 2015 to February 2016. Urine specimens from all patients were tested (including urine culture testing and antibiotic susceptibility) and infections were defined as uncomplicated or complicated UTIs.

RESULTS

1245 participants from 58 medical practices were enrolled in the study. Pathogenic organisms were found in the urine of 877 patients, of whom 74.5% had E. coli infections. Among the E.-coli-positive UTIs, 52.4% were classified as uncomplicated and 47.6% as complicated. The prevalence of E. coli that was resistant to TMP and to TMP/SMX in uncomplicated UTIs was 15.2% and 13.0%, respectively, compared to 25.3% and 24.4%, respectively, from all UTIs in ARS in 2015. Study participants who had previously taken antibiotics had the highest prevalence of E. coli resistance (30.9%), followed by those who had two or more UTIs within the past six months (28.9%).

CONCLUSION

E. coli with resistance to TMP was significantly less prevalent among the study patients with uncomplicated UTIs than in the routine data of the ARS. Accordingly, TMP should still be considered as an option for the treatment of uncomplicated UTIs. TMP/SMX is considered the agent of second choice because of its side effects. Surveillance systems based on routine data do not yield a representative sample for the evaluation of the resistance situation in patients with uncomplicated UTIs.

Overtesting and undertesting in primary care: a systematic review and meta-analysis

BACKGROUND

Health systems are currently subject to unprecedented financial strains. Inappropriate test use wastes finite health resources (overuse) and delays diagnoses and treatment (underuse). As most patient care is provided in primary care, it represents an ideal setting to mitigate waste.

OBJECTIVE

To identify overuse and underuse of diagnostic tests in primary care.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES AND ELIGIBILITY CRITERIA

We searched MEDLINE and Embase from January 1999 to October 2017 for studies that measured the inappropriateness of any diagnostic test (measured against a national or international guideline) ordered for adult patients in primary care.

RESULTS

We included 357 171 patients from 63 studies in 15 countries. We extracted 103 measures of inappropriateness (41 underuse and 62 overuse) from included studies for 47 different diagnostic tests.The overall rate of inappropriate diagnostic test ordering varied substantially (0.2%-100%)%).17 tests were underused >50% of the time. Of these, echocardiography (n=4 measures) was consistently underused (between 54% and 89%, n=4). There was large variation in the rate of inappropriate underuse of pulmonary function tests (38%-78%, n=8).Eleven tests were inappropriately overused >50% of the time. Echocardiography was consistently overused (77%-92%), whereas inappropriate overuse of urinary cultures, upper endoscopy and colonoscopy varied widely, from 36% to 77% (n=3), 10%-54% (n=10) and 8%-52% (n=2), respectively.

CONCLUSIONS

There is marked variation in the appropriate use of diagnostic tests in primary care. Specifically, the use of echocardiography (both underuse and overuse) is consistently poor. There is substantial variation in the rate of inappropriate underuse of pulmonary function tests and the overuse of upper endoscopy, urinary cultures and colonoscopy.

PROSPERO REGISTRATION NUMBER

CRD42016048832.