Antibiotic treatment failure of uncomplicated urinary tract infections in primary care
Abstract Background 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 dif...
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| Format: | Article |
| Language: | English |
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BMC
2023-08-01
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| Series: | Antimicrobial Resistance and Infection Control |
| Subjects: | |
| Online Access: | https://doi.org/10.1186/s13756-023-01282-4 |
| _version_ | 1827875395300491264 |
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| author | Sky Wei Chee Koh Tracy Si Min Ng Victor Weng Keong Loh Jun Cong Goh Si Hui Low Wei Zhi Tan Hung Chew Wong Pradeep Durai Louisa Jin Sun Doris Young Paul Anantharajah Tambyah |
| author_facet | Sky Wei Chee Koh Tracy Si Min Ng Victor Weng Keong Loh Jun Cong Goh Si Hui Low Wei Zhi Tan Hung Chew Wong Pradeep Durai Louisa Jin Sun Doris Young Paul Anantharajah Tambyah |
| author_sort | Sky Wei Chee Koh |
| collection | DOAJ |
| description | Abstract Background 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. Methods 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. Results 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. Conclusion 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. |
| first_indexed | 2024-03-12T17:06:09Z |
| format | Article |
| id | doaj.art-820e7fa5ff19459b981a91abc601c324 |
| institution | Directory Open Access Journal |
| issn | 2047-2994 |
| language | English |
| last_indexed | 2024-03-12T17:06:09Z |
| publishDate | 2023-08-01 |
| publisher | BMC |
| record_format | Article |
| series | Antimicrobial Resistance and Infection Control |
| spelling | doaj.art-820e7fa5ff19459b981a91abc601c3242023-08-06T11:25:06ZengBMCAntimicrobial Resistance and Infection Control2047-29942023-08-011211810.1186/s13756-023-01282-4Antibiotic treatment failure of uncomplicated urinary tract infections in primary careSky Wei Chee Koh0Tracy Si Min Ng1Victor Weng Keong Loh2Jun Cong Goh3Si Hui Low4Wei Zhi Tan5Hung Chew Wong6Pradeep Durai7Louisa Jin Sun8Doris Young9Paul Anantharajah Tambyah10National University Polyclinics, National University Health SystemDepartment of Family Medicine, National University Health SystemDivision of Family Medicine, Yong Loo Lin School of Medicine, National University of SingaporeNational University Polyclinics, National University Health SystemNational University Polyclinics, National University Health SystemNational University Polyclinics, National University Health SystemBiostatistics Unit, Yong Loo Lin School of Medicine, National University of SingaporeDivision of Urology, Department of General Surgery, Ng Teng Fong General HospitalInfectious Diseases, Alexandra Hospital, National University Health SystemDivision of Family Medicine, Yong Loo Lin School of Medicine, National University of SingaporeDepartment of Medicine, Yong Loo Lin School of Medicine, National University of SingaporeAbstract Background 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. Methods 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. Results 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. Conclusion 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.https://doi.org/10.1186/s13756-023-01282-4General practicePrimary careUrinary tract infectionsAntibioticTreatment failureEffectiveness |
| spellingShingle | Sky Wei Chee Koh Tracy Si Min Ng Victor Weng Keong Loh Jun Cong Goh Si Hui Low Wei Zhi Tan Hung Chew Wong Pradeep Durai Louisa Jin Sun Doris Young Paul Anantharajah Tambyah Antibiotic treatment failure of uncomplicated urinary tract infections in primary care Antimicrobial Resistance and Infection Control General practice Primary care Urinary tract infections Antibiotic Treatment failure Effectiveness |
| title | Antibiotic treatment failure of uncomplicated urinary tract infections in primary care |
| title_full | Antibiotic treatment failure of uncomplicated urinary tract infections in primary care |
| title_fullStr | Antibiotic treatment failure of uncomplicated urinary tract infections in primary care |
| title_full_unstemmed | Antibiotic treatment failure of uncomplicated urinary tract infections in primary care |
| title_short | Antibiotic treatment failure of uncomplicated urinary tract infections in primary care |
| title_sort | antibiotic treatment failure of uncomplicated urinary tract infections in primary care |
| topic | General practice Primary care Urinary tract infections Antibiotic Treatment failure Effectiveness |
| url | https://doi.org/10.1186/s13756-023-01282-4 |
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