Long-term impact of fluoroquinolone-sparing strategies for empirical treatment of acute uncomplicated cystitis among ambulatory patients

BACKGROUND: Acute uncomplicated cystitis is common among outpatients and frequently leads to antibiotic prescriptions, making urinary tract infections (UTIs) an important area for antimicrobial stewardship initiatives. Infectious Disease Society of America (IDSA) guidelines promote alternative agents in place of fluoroquinolones for acute uncomplicated cystitis. Despite IDSA guidance, adherence to the guideline remains low in the United States (US). Several studies have described interventions to improve guideline-concordant prescribing for UTIs. However, the long-term sustainability and impact of fluoroquinolone (FLQ)-sparing strategies on community antimicrobial resistance and treatment outcomes are unknown. The objectives of this study were to characterize current antibiotic prescribing patterns, treatment failures and Escherichia coli resistance rates in a setting which instituted FLQ sparing strategies for UTIs in 2007. METHODS: Retrospective cohort study of women aged ⩾ 18 diagnosed with acute uncomplicated cystitis based on International Classification of Diseases, 10th Revision (ICD-10) codes were included. Data were abstracted for ambulatory visits over a 6-month period, January 2018 to June 2018, at a large urban health care system. Treatment decisions were made by individual providers, and data were analyzed retrospectively. Nitrofurantoin (NFT) resistance was obtained from the institutional antibiogram and patient-level data. Treatment failure was defined as the need for a different antibiotic for UTI within 28 days of the original prescription. RESULTS: NFT was the most frequently prescribed antibiotic (n = 386, 71.6%) of empiric antibiotic prescriptions for UTIs. FLQs comprised 4.6% of all antibiotic prescriptions (n = 25). Treatment failure rate was 2.3% in patients treated with NFT. Urine culture was ordered for only 26.8% of patients. Among the small group of patients with cultures ordered, E. coli remained 98.5% susceptible to NFT. CONCLUSIONS: This study is the first to report significantly low rates (4.6%) of FLQ prescribing for acute uncomplicated cystitis. Treatment failure rate was low with empiric NFT. Increased NFT resistance among E. coli was not observed at the institution or among the subset of patients with E. coli positive urine cultures. These findings support current IDSA treatment guidance for uncomplicated cystitis.