Antimicrobial Resistance in Urinary Tract Infections: Is There an Issue and Does It Matter? - European Medical Journal

Continue

Antimicrobial Resistance in Urinary Tract Infections: Is There an Issue and Does It Matter?

6 Mins
Microbiology & Infectious Diseases
Download PDF

This congress review is based on sessions of interest that took place between 20th–22nd October 2022, as part of IDWeek2022 held in Washington, D.C., USA

Speakers:
Keith Kaye,1 Erin McCreary,2 Claire Trennery,3 Rodrigo Mendes4

1. Department of Medicine, Rutgers–Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
2. Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pennsylvania, USA
3. Value Evidence Outcomes, GSK, Brentford, UK
4. JMI Laboratories, North Liberty, Iowa, USA

Disclosure:

Kaye is a consultant for Merck, Allecra Therapeutics, Spero Therapeutics, Shionogi, UTILITY Therapeutics, GSK, Qpex Biopharma, Cipla, and CARB-X; has received speaker honoraria from GSK; and grant support from National Institutes of Health (NIH), Agency for Healthcare Research and Quality (AHRQ), and Merck. McCreary has received speaker honoraria from GSK and Shionogi; and has served as a consultant for AbbVie, Cidara Therapeutics, Entasis Pharmaceuticals, Ferring Pharmaceuticals/Rebiotix, La Jolla Pharmaceuticals Company, LabSimply, MeMed Diagnostics, Merck, Shionogi, and Summit Pharmaceuticals. Trennery is an employee of and owns stocks in GSK. Mendes has received grant funding from AbbVie, Cidara Therapeutics, GSK, Melinta Therapeutics, Nabriva Therapeutics, Office for Assistant Secretary of Defense for Health Affairs, Pfizer, Shionogi, and Spero Therapeutics.

Kaye is a consultant for Merck, Allecra Therapeutics, Spero Therapeutics, Shionogi, UTILITY Therapeutics, GSK, Qpex Biopharma, Cipla, and CARB-X; has received speaker honoraria from GSK; and grant support from National Institutes of Health (NIH), Agency for Healthcare Research and Quality (AHRQ), and Merck. McCreary has received speaker honoraria from GSK and Shionogi; and has served as a consultant for AbbVie, Cidara Therapeutics, Entasis Pharmaceuticals, Ferring Pharmaceuticals/Rebiotix, La Jolla Pharmaceuticals Company, LabSimply, MeMed Diagnostics, Merck, Shionogi, and Summit Pharmaceuticals. Trennery is an employee of and owns stocks in GSK. Mendes has received grant funding from AbbVie, Cidara Therapeutics, GSK, Melinta Therapeutics, Nabriva Therapeutics, Office for Assistant Secretary of Defense for Health Affairs, Pfizer, Shionogi, and Spero Therapeutics.

Acknowledgements:

Medical writing assistance was provided by Hannah Moir, EMJ, London, UK. All speakers were given the opportunity to review the article.

Disclaimer:

The views and opinions expressed in this article are exclusively those of the speakers and do not necessarily reflect those of GSK. GSK was provided with the opportunity to review this publication for the sole purpose of ensuring that its data is accurately stated herein. Not all medicines and/or indications presented in this report may be approved for use in all countries. The speakers listed are GSK paid healthcare providers or GSK employees. The content is intended to support disease state education and is considered non-promotional. The Learning Lounge was neither endorsed nor sponsored by IDWeek.

Support:

The Learning Lounge and the publication of this article were funded by GSK.

Citation:
EMJ Microbiol Infect Dis. ;4[Suppl 2]:2-9. DOI/10.33590/emjmicrobiolinfectdis/10127137. https://doi.org/10.33590/emjmicrobiolinfectdis/10127137.

Each article is made available under the terms of the Creative Commons Attribution-Non Commercial 4.0 License.

Meeting Summary

Antimicrobial resistance (AMR) has increased substantially among community-acquired uropathogens that cause urinary tract infections (UTI), limiting the availability of effective oral antibiotic treatments.

This review includes coverage of an expert-led Learning Lounge, symposium session, and several poster presentations, that took place between 20th–22nd October 2022 as part of IDWeek2022 in Washington, D.C., USA.

An immersive Learning Lounge, sponsored by GSK, opened with Keith Kaye, Department of Medicine, Rutgers–Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA, who illuminated the concerns of AMR in community-acquired UTIs, delivering contemporary surveillance data, and outlined how in vitro data may translate into practical advice. This led fittingly to Erin McCreary, Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pennsylvania, USA, who enquired whether enough is being done in clinical practice regarding community-acquired infections, highlighting the importance of antimicrobial stewardship (AMS), and galvanising the audience to adapt healthcare settings to the changing landscape.

The scientific programme also included three data-rich posters that showcased Kaye’s surveillance data on Escherichia coli and Klebsiella pneumoniae co-resistance, along with the geographical distribution of K. pneumoniae. An insightful poster by Claire Trennery, Value Evidence Outcomes, GSK, Brentford, UK, considered the patient perspective of UTI symptoms in defining antibiotic treatment success, and two posters presented by Rodrigo Mendes, JMI Laboratories, North Liberty, Iowa, USA, examined in vitro global surveillance data of emerging antimicrobial treatments.

Introduction

Community-acquired UTIs are associated with infections arising in community settings, and are categorised in patients who attend primary care settings such as an outpatient clinic or the emergency department without being admitted.1,2

In recent years, there has been a notable increase in AMR and multi-drug resistance (MDR) among community-acquired uropathogens causing UTIs, predominantly associated with E. coli,3-5 and K. pneumoniae.6-8 The number of effective oral treatments limited by AMR is of growing concern.9 Organisations such as the World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) in the USA prioritise several critical drug-resistant pathogens for new antibiotic treatments, including carbapenem-resistant, third-generation cephalosporin-resistant, and extended-spectrum β-lactamase (ESBL)-producing Enterobacterales.10-12

This congress review describes the epidemiology of AMR in community-acquired UTIs, the importance of AMS, and the emergence of prospective antimicrobial treatments.

Antimicrobial Resistance in Community-Acquired Urinary Tract Infections: Are We Doing Enough in Practice?

Keith Kaye and Erin McCreary

An interactive GSK-sponsored ‘Learning Lounge’ educational session, attended by a range of healthcare professionals, opened with Kaye highlighting the concerns of AMR in the community setting and positing the question: “What is the issue and why should we care?” He positioned this with an audience polling question: “Do you believe antimicrobial resistance is currently an increasing problem in community-acquired infections?” Despite respondents acknowledging AMR as a public health issue, several respondents did not believe the issue concerned them in their practice.

The Global Surveillance of Antimicrobial Resistance in Community-Acquired Urinary Tract Infections

Until recently, little was known about AMR prevalence in community-acquired UTIs due to limited public health surveillance data.13 Treatment approaches for UTIs often use empiric antibiotic therapy, where requests for urine cultures are low (approximately equal to 17% of patient cases),14 as they are not routinely recommended.

An increase in community-associated ESBL-related infections was seen between 2012–2017,12 and according to CDC data,11 major pathogenic threats are ESBL-producing Enterobacterales. Kaye stated this was “driven primarily, almost exclusively, by E. coli in the CTX-M ESBL, which has become the single-most common ESBL in the world in a very short period.”

Kaye identified that regardless of global location, AMR of community-acquired E. coli isolates is of concern, particularly for fluoroquinolones (FQ) and trimethoprim-sulfamethoxazoles (TMP-SMX).15-21

A study of community-acquired urinary E. coli isolates identified an elevated and persistently prevalent AMR to commonly prescribed antimicrobials, with 25.4% to TMP-SMX and 21.1% to FQ. Of the isolates, 6.4% were ESBL-positive (+), and 14.4% had ≥2 drug-resistant phenotypes.22 Likewise, Kaye emphasised the disconcerting increase in AMR among K. pneumoniae urine-isolates, with high resistance to β-lactams (>80%), nitrofurantoin (NFT; >50%), TMP-SMX (11.3%), FQ (6.8%), and 7.2% ESBL-producing phenotype.15

Kaye stipulated that raising awareness of current regional patterns of non-susceptible E. coli and K. pneumoniae isolates from community-acquired UTIs is important for guiding physicians empiric treatment decisions, and demonstrates the need for AMS efforts and use of appropriate surveillance data in community settings.

The Rising Prevalence of Co-Resistance in Community-Acquired Urinary Tract Infections

Considering co-resistance in community-acquired UTIs, Kaye referred to surveillance data, showcasing two data-rich posters. Co-resistance was defined as the presence of two or more of the four resistance phenotypes assessed (ESBL+, FQs, NFT, and TMP-SMX).

These surveillance datasets indicated a high prevalence of co-resistance in E. coli,23 and K. pneumoniae isolates.24 For E. coli, this was particularly towards ESBL+ isolates where 6.4% were ESBL+; while 21.1% were not susceptible to FQ, 25.4% to TMP-SMX, and 3.7% to NFT, with co-resistance to FQ (>70%) and 6.8% co-resistant to all four phenotypes observed (Table 1).23

Table 1: Co-resistant phenotypes in community-acquired Escherichia coli urine cultures from females aged ≥12 years, taken in 2011–2019 in the USA.23
ESBL+: extended-spectrum β-lactamase-positive; FQ: fluoroquinolone; NFT: nitrofurantoin; N/A: not applicable; NS: not-susceptible; TMP-SMX: trimethoprim-sulfamethoxazole.

For K. pneumoniae, similar trends were shown, with co-resistance towards NFT (70–80% of isolates).24 Of the isolates, 4.4% were ESBL+; while 4.4% were not-susceptible to FQ, 9.5% to TMP-SMX, 56.5% to NFT, and 38.2% were co-resistant to all four phenotypes (Table 2).24

Table 2: Co-resistant phenotypes in community-acquired Klebsiella pneumoniae urine cultures from females aged ≥12 years, taken in 2011–2019 in the USA.24
ESBL+: extended-spectrum β-lactamase-positive; FQ: fluoroquinolone; NFT: nitrofurantoin; N/A: not applicable; NS: not-susceptible; TMP-SMX: trimethoprim-sulfamethoxazole.

As affirmed by Kaye, these findings indicate limited effective oral antibiotic treatment options for community-acquired UTIs and emphasise the need for ongoing surveillance and improved clinician awareness of current AMR patterns to help inform appropriate empiric prescribing practices.23

Furthering this work, Kaye presented another poster regarding K. pneumoniae isolates, where the prevalence of all phenotypes increased over time, except NFT, which declined by 0.3%.25 Overall, ESBL+ increased 4.6%, and the prevalence of resistance was highest for NFT (56.6%), followed by TMP-SMX (9.6%) and FQ (4.4%), with trends of increasing resistance seen in older patients.25

Kaye emphasised the need for appropriate antibiotic prescribing, demonstrating treatment failure in 34.3% of patients (n=5,395) treated empirically with an antibiotic to which the pathogen was not susceptible.26 Treatment with FQ in non-susceptible isolates resulted in 36% re-prescriptions (or additional antibiotic prescriptions), and a two-fold increase (17%) in hospitalisation, compared to treatment of a susceptible pathogen.26

Kaye concluded that AMR in community-acquired UTIs is likely to get worse, and that healthcare professionals should pay more attention to the importance of AMR and AMS.

Implications for Rising Antimicrobial Resistance and Implementing Antimicrobial Stewardship

Continuing the Learning Lounge session, McCreary proceeded with a discussion addressing this global health priority through the role of AMS. With passion for this issue, McCreary discussed the importance of shifting focus to the community setting, with a focus on risk factors for non-susceptible pathogens.

The biggest risk factors for AMR in community-acquired UTIs include being over 55 years, residing in a nursing home, or being bedridden. Other risk factors include having a history of recurrent UTIs, multiple medical comorbidities, multiple hospitalisations, and antibiotic exposures.13,27,28 Those with UTIs caused by drug-resistant pathogens may often have a urinary catheter or neurogenic bladder.29,30

McCreary presented an interesting insight, that AMR transmission is greatest in the community setting, such as residential care31-33 and household transmission.34,35 A lack of community-based AMS programmes results in less controlled antibiotic use, supporting the notion of Kaye that efforts to decrease the spread of AMR are clinically important.36

Ambassadors of Antimicrobial Stewardship in the Community

In 2019, the Infectious Diseases Society of America (IDSA) guidelines affirmed that AMR was driven by unnecessary antibiotic use, and that community stewardship initiatives should tackle this.37

McCreary expressed the importance of not treating asymptomatic bacteriuria or non-specific symptoms with antibiotics, asking “are we causing harm to patients in the community [such as those presenting only with altered mental status] if we do not give them an antibiotic?” The ImpresU study38,39 highlighted that reducing antibiotic prescriptions in frail elderly patients by recommending a watchful waiting strategy over antibiotic prescriptions had no impact on secondary outcomes (complications, hospitalisations, mortality rate), but was able to significantly decrease antibiotic exposure.

McCreary also stipulated that for patients with legitimate infections, selecting an appropriate first-line empirical antibiotic with in vitro activity against the causative pathogen as soon as possible is important.29,40 McCreary also emphasised the use of local antimicrobial susceptibility rates, as highlighted by Kaye, when determining the appropriate empiric agent for one’s practice. McCreary extended this by referring to a UK-based primary care study that found 85.7% of UTI cases had received a prescribed antibiotic on the day of diagnosis, with 4.1% receiving a re-prescription for the same UTI episode.41 Thus, over 4 years, approximately 20,000 patients had received a second antibiotic due to failure to appropriately treat the infection empirically.41

McCreary also reminded the audience of the U.S. Food and Drug Administration (FDA) warning to avoid FQ42,43 due to highly-prevalent E. coli resistance in community-acquired upper UTIs (uUTI), and more toxicities compared to other antimicrobial classes authorised for the treatment of uUTI. Following this warning,42,43 FQ prescribing has significantly reduced (19.2% versus >40% prior), yet approximately one in five prescribers still recommend FQs first-line, signifying the ongoing need for AMS in the community.44

The Springboard for Antimicrobial Stewardship – Taking Responsibility

Antibiotic stewardship was making good progress until the COVID-19 pandemic, which led to a shifting of stewardship resources to pandemic response, resulting in more indiscriminate antimicrobial use in hospitals, an increase of ESBLs during hospitalisation, and more community-prescribed azithromycin, indicating a heightened threat to AMR.45

McCreary recapped a survey of general care community practitioners based in the USA (n=1,550), which elucidated most community providers acknowledged the importance of AMR (94%), but that only around half (55%) recognise the issue as their problem.46

The majority of the providers (93%) identified that inappropriate outpatient prescribing accelerates the emergence of AMR, yet only 37% identified that the problem exists in their own practice.46 When it came to taking responsibility for AMR in the community, most (91%) recognised that inappropriate outpatient prescribing was a problem, yet 60% felt that they prescribed antibiotics more appropriately than their peers.46 Lastly, despite 72% supporting the use of AMS programmes to address AMR, over half (53%) believed all they needed to do was talk with patients about the value of an antibiotic for their symptoms.46

McCreary concluded that there is a communal need for AMS ambassadors to educate and engage all healthcare practitioners in taking responsibility to decrease the spread of AMR in community-acquired UTI.46

The Learning Lounge highlighted the importance of surveillance data to drive decision-making in clinical practice, where outcomes data is crucial for demonstrating improved practice. Finally, community stewardship to address rising AMR in the community setting requires regional approaches, including public health campaigns to educate practitioners and patients to decrease antibiotic use.

POSTER PRESENTATIONS

Patient Experiences of Urinary Tract Infection: The Expectation of Complete Symptom Resolution

Claire Trennery

Determining UTI antibiotic treatment success requires assessing microbiological and clinical resolution (i.e., the complete resolution of symptoms [dysuria, urinary frequency, urinary urgency, and suprapubic pain]).47,48 However, the meaningfulness, and definition of treatment success, is rarely explored from the perspective of the patient experience.

A poster presented by Trennery, which garnered a lot of interest, determined what antibiotic treatment success meant to patients.49 The cross-sectional study conducted interviews with females with a confirmed uUTI diagnosis.49 Before treatment, the most common symptoms were urinary urgency (97%), retention (87%), frequency (83%), and dysuria (80%). Nearly all (97%) reported that the uUTI had impacted their mood or emotions, describing feelings of sadness, irritability, and aggravation.49

Almost all (90%) defined treatment success as when they no longer experienced any clinical symptoms by the end of the treatment period. Most (80%) scored each symptom as ‘none’ (zero), and reported this was meaningful or important.49 Participants who felt their treatment was successful reported that their day-to-day lives returned to normal.

These findings indicate patients experience a range of UTI symptoms that impact their quality of life. This insightful work supports the need to include complete clinical resolution endpoints, as well as valid scales of assessment in regulatory guidelines.

Emerging Antimicrobials for Community-Acquired Urinary Tract Infections

Rodrigo Mendes

With the continued threat of E. coli resistance and MDR in community-acquired UTIs, an alternative urgent treatment is required. Mendes presented a poster that garnered interest on in vitro data of emerging prospective antimicrobial treatments.

The study investigated the activity of oral antibiotics against E. coli subsets from community-acquired UTIs which observed high rates not susceptible to commonly used oral agents (e.g., FQs and TMP-SMX).50 A presumptive ESBL phenotype further compromised the activity of oral agents, including oral cephalosporins.

This data supports the need for further clinical development of novel antibiotic therapies as a treatment option for uUTIs caused by E. coli, including resistant isolates against which other oral treatment options are limited.

CONCLUSION

Across IDWeek2022 the fight against AMR in community-acquired UTIs was highlighted. Reflecting on the impact of surveillance data, a key recommendation was advocating community-based AMS, and fulfilling the patients’ desire for clinical resolution. Additionally, the development of new antimicrobial treatments has promise, but responsibility for appropriate empiric treatment decisions is needed at the practitioner level.

References
Bjerklund Johansen TE et al. Critical review of current definitions of urinary tract infections and proposal of an EAU/ESIU classification system. Int J Antimicrob Agents. 2011;38(Suppl):64-70. Stapleton AE et al. Escherichia coli resistance to fluoroquinolones in community-acquired uncomplicated urinary tract infection in women: a systematic review. Antimicrob Agents Chemother. 2020;64(10):e00862-20. Chen HE et al. Trends in antimicrobial susceptibility of Escherichia coli isolates in a Taiwanese child cohort with urinary tract infections between 2004 and 2018. Antibiotics. 2020;9(8):E501. Frazee BW et al. Emergency department urinary tract infections caused by extended-spectrum β-lactamase-producing enterobacteriaceae: many patients have no identifiable risk factor and discordant empiric therapy is common. Ann Emerg Med. 2018;72(4):449-56. Lob SH et al. Susceptibility patterns and ESBL rates of Escherichia coli from urinary tract infections in Canada and the United States, SMART 2010–2014. Diagn Microbiol Infect Dis. 2016;85(4):459-65. Ameshe A et al. Antimicrobial resistance patterns, extended-spectrum beta-lactamase production, and associated risk factors of klebsiella species among UTI-suspected patients at Bahir Dar city, Northwest Ethiopia. Int J Microbiol. 2022:8216545. Thänert R et al. Comparative genomics of antibiotic-resistant uropathogens implicates three routes for recurrence of urinary tract infections. mBio. 2019;10(4):e01977-19. Flores-Mireles AL et al. Urinary tract infections: epidemiology, mechanisms of infection and treatment options. Nat Rev Microbiol. 2015;13(5):269-84. Ballén V et al. Antibiotic resistance and virulence profiles of Klebsiella pneumoniae strains isolated from different clinical sources. Front Cell Infect Microbiol. 2021;11:738223. World Health Organization (WHO). Prioritization of pathogens to guide discovery, research and development of new antibiotics for drug-resistant bacterial infection, including tuberculosis. 2017. Available at: https://www.who.int/publications/i/item/WHO-EMP-IAU-2017.12. Last accessed: 22 October 2022. Centers for Disease Control and Prevention (CDC). Antibiotic resistance threats in the United States 2019. 2019. Available at: https://www.cdc.gov/drugresistance/pdf/threats-report/2019-ar-threats-report-508.pdf. Last Accessed: 22 October 2022. Jernigan JA et al. Multidrug-resistant bacterial infections in U.S. hospitalized patients, 2012–2017. N Engl J Med. 2020;382(14):1309-19. Wagenlehner F et al. A global perspective on improving patient care in uncomplicated urinary tract infection: expert consensus and practical guidance. J Glob Antimicrob Resist. 2022;28:18-29. Ganzeboom KMJ et al. Urine cultures and antibiotics for urinary tract infections in Dutch general practice. Prim Health Care Res Dev. 2018;20:1-8. Dunne MW et al. A multicenter analysis of trends in resistance in urinary Enterobacterales isolates from ambulatory patients in the United States: 2011–2020. BMC Infect Dis. 2022;22:194. Kresken M et al. Resistance to mecillinam and nine other antibiotics for oral use in Escherichia coli isolated from urine specimens of primary care patients in Germany, 2019/20. Antibiotics. 2022;11(6):751. Garcia-Menino I et al. Occurrence and genomic characterization of clone ST1193 clonotype 14–64 in uncomplicated urinary tract infections caused by Escherichia coli in Spain. Microbiol Spectr. 2022;10(3):e0004122. Tano ZN et al. Susceptibility to first choice antimicrobial treatment for urinary tract infections to Escherichia coli isolates from women urine samples in community South Brazil. Braz J Infect Dis. 2022;26(3):102366. Jia P et al. High prevalence of extended-spectrum beta-lactamases in Escherichia coli strains collected from strictly defined community-acquired urinary tract infections in adults in China: a multicenter prospective clinical microbiological and molecular study. Front Microbiol. 2021;12:663033. Rizvi ZA et al. Exploring antimicrobial resistance in agents causing urinary tract infections at a tertiary care hospital in a developing country. Cureus 2020;12(8):e9735. Ait-Mimoune N et al. Bacteriological profile of urinary tract infections and antibiotic susceptibility of Escherichia coli in Algeria. Iran J Microbiol. 2022;14(2):156-60. Kaye KS et al. Antimicrobial resistance trends in urine Escherichia coli isolates from adult and adolescent females in the United States from 2011 to 2019: rrising ESBL strains and impact on patient management. Clin Infect Dis. 2021;73(11):1992-9. Kaye KS et al. Analysis of co-resistance among Escherichia coli urine isolates from female outpatients in the United States. Abstract 2225. IDWeek2022, 19-23 October, 2022. Kaye KS et al. Analysis of co-resistance among Klebsiella pneumoniae urine isolates from female outpatients in the United States. Abstract 2226. IDWeek2022, 19-23 October, 2022. Kaye KS et al. Prevalence, regional distribution, and trends of antimicrobial resistance among female outpatients with urine Klebsiella pneumoniae isolates: a multicenter evaluation. Abstract 2227. IDWeek2022, 19-23 October, 2022. Dunne et al. Impact of empirical antibiotic therapy on outcomes of outpatient urinary tract infection due to nonsusceptible Enterobacterales. Microbiol Spectr. 2022;10(1):e0235921. Goyal D et al. Risk factors for community-acquired extended-spectrum beta-lactamase-producing Enterobacteriaceae infections-a retrospective study of symptomatic urinary tract infections. Open Forum Infect Dis. 2019;6(2):ofy357. Kanda N et al. Gram-negative organisms from patients with community-acquired urinary tract infections and associated risk factors for antimicrobial resistance: a single-center retrospective observational study in Japan. Antibiotics. 2020;9:438. Bonkat G et al. European Association of Urology (EAU) guidelines on urological infections. 2022. Available at: https://d56bochluxqnz.cloudfront.net/documents/full-guideline/EAU-Guidelines-on-Urological-Infections-2022.pdf. Last accessed: 22 October 2022. Wagenlehner FME et al. Epidemiology, definition and treatment of complicated urinary tract infections. Nat Rev Urol 2020;17(10):586-600. van den Dool C et al. The role of nursing homes in the spread of antimicrobial resistance over the healthcare network. Infect Control Hosp Epidemiol. 2016;37(7):761-7. Harrison EM et al. Transmission of methicillin-resistant Staphylococcus aureus in long-term care facilities and their related healthcare networks. Genome Med. 2016;8(1):102. Rosello A et al. Impact of long-term care facility residence on the antibiotic resistance of urinary tract Escherichia coli and Klebsiella. J Antimicrob Chemother 2017;72(4):1184-92. Martischang R et al. Household carriage and acquisition of extended-spectrum β-lactamase-producing Enterobacteriaceae: a systematic review. Infect Control Hosp Epidemiol 2020;41(3):286-294. Stewardson AJ et al. Effect of outpatient antibiotics for urinary tract infections on antimicrobial resistance among commensal Enterobacteriaceae: a multinational prospective cohort study. Clin Microbiol Infect 2018;24(9):972-9. Hammond A et al. Antimicrobial resistance associations with national primary care antibiotic stewardship policy: primary care-based, multilevel analytic study. PLoS One. 2020;15(5):e0232903. Nicolle LE et al. Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America. Clin Infect Dis. 2019;68(10):e83-110. Hartman EAR et al. Multifaceted antibiotic stewardship intervention using a participatory-action-research approach to improve antibiotic prescribing for urinary tract infections in frail elderly (ImpresU): study protocol for a European qualitative study followed by a pragmatic cluster randomised controlled trial. BMJ Open. 2021;11(10):e052552. Hartman E et al. Factors contributing to decisions on antibiotic prescribing for suspected urinary tract infections in frail older adults: a qualitative study. Abstract P1419. The European Congress of Clinical Microbiology & Infectious Diseases (ECCMID) 2022, 23-26 April, 2022. Goebel MC et al. The five Ds of outpatient antibiotic stewardship for urinary tract infections. Clin Microbiol Rev. 2021;34(4):e00003-20. Pujades-Rodriguez M et al. Lower urinary tract infections: management, outcomes and risk factors for antibiotic re-prescription in primary care. EClinicalMedicine. 2019;14:23-31. U.S. Food and Drug Administration (FDA). FDA drug safety communication. 2016. Available at: https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-advises-restricting-fluoroquinolone-antibiotic-use-certain. Last accessed: 24 October 2022. European Medicines Agency (EMA). Disabling and potentially permanent side effects lead to suspension or restrictions of quinolone and fluoroquinolone antibiotics. 2019. Available at: https://www.ema.europa.eu/en/documents/referral/quinolone-fluoroquinolone-article-31-referral-disabling-potentially-permanent-side-effects-lead_en.pdf. Last accessed: 25 October 2022. Tran PT et al. Association of US Food and Drug Administration removal of indications for use of oral quinolones with prescribing trends. JAMA Intern Med. 2021;181(6):808-16. Centers for Disease Control and Prevention (CDC). COVID-19: US impact on antimicrobial resistance. 2022. Available at: https://www.cdc.gov/drugresistance/pdf/covid19-impact-report-508.pdf. Last accessed: 24 October 2022. Zetts RM et al. Primary care physicians' attitudes and perceptions towards antibiotic resistance and antibiotic stewardship: a national survey. Open Forum Infect Dis. 2020;7(7):ofaa244. U.S. Food and Drug Administration (FDA). Uncomplicated urinary tract infections: developing drugs for treatment guidance for industry. 2019. Available at: https://www.fda.gov/media/129531/download. Last accessed: 19 October 2022. European Medicines Agency (EMA). Guideline on the evaluation of medicinal products indicated for treatment of bacterial infections. 2018. Available at: https://www.ema.europa.eu/en/documents/scientific-guideline/guideline-evaluation-medicinal-products-indicated-treatment-bacterial-infections-revision-3_en.pdf. Last accessed: 19 October 2022. Trennery CL et al. Patient perceptions of treatment success in uncomplicated urinary tract infection. Abstract 2243. IDWeek2022, 19-23 October, 2022. Mendes RE et al. Activity of gepotidacin tested against molecularly characterized Escherichia coli isolates resistant to commonly used oral therapies for UTI in the US (2019–2020). Abstract 1675. IDWeek2022, 19-23 October, 2022.

Please rate the quality of this content

As you found this content interesting...

Follow us on social media!

We are sorry that this content was not interesting for you!

Let us improve this content!

Tell us how we can improve this content?