jac 2000 sup. vigilancia de antibióticos en ivu

8/18/2019 JAC 2000 Sup. Vigilancia de Antibióticos en IVU

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Journal of Antimicrobial Chemotherapy (2000) 46, Suppl. S1, 49–52

Introduction

Guidelines for the appropriate and rational prescribingof antibacterial agents are being produced increasinglyfrequently. While antibiotic-prescribing policies for uselocally in a particular hospital have existed for many years,newer guidelines are more comprehensive, in that they aremore detailed and are not intended just for local use. They

include not only recommendations concerning which anti-bacterials to prescribe, but also appropriate doses, durationof therapy and broader aspects of management, includinglaboratory investigations.1–3 Current guidelines for themanagement of urinary tract infections (UTIs) are summa-rized elsewhere in this supplement.4

With the increasing promulgation of guidelines, it isinstructive to compare expert opinion on disease manage-ment with the actual usage of antimicrobials in practice.This report summarizes the results of an interactive sessioninvolving delegates at an international symposium onUTIs.

Materials and methods

Ninety-two symposium delegates, including microbiologists,infectious disease specialists and clinicians with an interest intherapy of UTIs, participated. This was an internationalgroup, 34 (37%) of the delegates coming from Nordic coun-tries (Denmark, Norway, Sweden or Finland), 19 (21%)from the UK or Eire, 13 (14%) from Germany, Austria orHolland, 10 (11%) from Canada, eight (9%) from France,Switzerland or Belgium, three (3%) from Italy, Spain,Portugal or Greece and five (5%) from other countries.

Questions were posed by a moderator and the delegatesused a key-pad to select an answer to each question. Theoverall response to each question was analysed and pre-sented to the participants for information and discussion.The answers, which represented the delegates’ perceiveduse of antibacterials, were compared with market data onactual use as provided by International Medical Statistics(IMS), Pinner, UK.

Results

Frequency of acute uncomplicated lower UTI

Before discussing the specific treatment of acute uncompli-cated lower UTI, delegates were asked whether the num-ber of prescriptions for this condition per annum permillion inhabitants in western Europe and Canada wasc.10 000, c.100000 or c.250 000 prescriptions. In fact, in1999, there were 46 million prescriptions per annum foracute uncomplicated lower UTI in western Europe and

Canada, corresponding to a mean of 110 000 prescriptionsper million inhabitants per annum. The delegates showed agood awareness of this: 14 (15%) of the delegates thoughtthere were c.10 000 prescriptions/year, 59 (64%) thoughtthere were c.100 000/year and 19 (21%) thought there werec.250 000 prescriptions/year.

First-line empirical treatment of acute uncomplicated

lower UTI

Symposium delegates were asked to indicate which of thefollowing was their first-line empirical therapy for acute

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Survey on antibiotic usage in the treatment of urinary tract infections

Kurt G. Naber*

Klinikum St Elisabeth Straubing GmbH, St Elisabeth Strasse 23, D-94315, Straubing, Germany

Ninety-two clinical microbiologists, infectious disease clinicians and clinicians with an interestin the management of urinary tract infections (UTIs) participated in an interactive sessionconcerning the management of acute uncomplicated lower UTI. The antibacterials consideredmost appropriate as first-line agents were trimethoprim, co-trimoxazole, pivmecillinam, nitro-furantoin and fluoroquinolones. The current level of usage of fluoroquinolones for lower UTIswas, however, considered inappropriate by most delegates from a ‘societal perspective’, in

terms of spread of resistance and potential impact on the environment.

*Corresponding author. Tel:49-94-21-710-1700; Fax:49-94-21-710-1015; E-mail: [email protected]

© 2000 The British Society for Antimicrobial Chemotherapy

JAC


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K. G. Naber

uncomplicated lower UTI: trimethoprim, co-trimoxazole,pivmecillinam, nitrofurantoin, fluoroquinolones, cephalo-sporins or ‘others’. Twenty-six (30%) of the delegateschose trimethoprim, 18 (19%) pivmecillinam, 17 (18%) co-trimoxazole, 10 (11%) nitrofurantoin, nine (10%) fluoro-

quinolones, three (3%) cephalosporins and nine (10%)‘others’.

Antibiotic treatment for acute uncomplicated lower

UTI

Delegates were asked to estimate the proportion of patientsin their country with acute uncomplicated lower UTItreated with fluoroquinolones. The options provided were0–10%, 11–20%, 21–30%, 31–40%, 41–50% or 51–71%.There was a broad range of estimates concerning fluoro-quinolone usage in acute uncomplicated UTI. Forty-two

(46%) of the delegates estimated that fluoroquinoloneswere used in 10% of patients with acute uncomplicatedlower UTIs. Seventeen (18%) estimated their usage in11–20%, 13 (14%) in 21–30%, 13 (14%) in 31–40% andseven (8%) in50% of patients with acute uncomplicatedlower UTIs.

The actual usage of antibiotics, expressed as a percentageof the total number of prescriptions for acute uncomplicatedlower UTI, is shown in Table I. Fluoroquinolones (and otherquinolones) are very widely used in the treatment of acuteuncomplicated lower UTI. They are particularly heavilyprescribed in Italy, Spain, Portugal, France, Switzerland andBelgium. There is less, but still considerable, use in Greece,Germany, Austria, The Netherlands and Canada. In the UKand Finland, use of these agents is lower.

Delegates were asked to state which of the following wasthe most frequently used antibiotic in western Europe andCanada for the treatment of acute uncomplicated UTI:

trimethoprim, co-trimoxazole, pivmecillinam, nitrofuran-toin, norfloxacin or ciprofloxacin. Delegates believed thatco-trimoxazole and trimethoprim were the most populartreatments in Europe and Canada (Table II). This was notthe case in 1998/9 (Table II). While there was considerable

use of these agents, the quinolones, particularly norfloxacinand ciprofloxacin, were the most popular antibacterialagents in the treatment of acute uncomplicated lower UTIin 1999.

Pivmecillinam usage in Nordic countries

Pivmecillinam is a widely used treatment for acute uncom-plicated lower UTI in Nordic countries. Participants wereasked to estimate whether 5–10%, 11–20%, 21–25%,26–30% or 30% of patients with acute uncomplicatedUTI were treated with pivmecillinam in Scandinavia

(Norway, Denmark and Sweden). Sixty-two delegatesresponded to this question; eight delegates (13%) esti-mated that 5–10% of patients with lower UTIs would beprescribed pivmecillinam, 23 (37%) chose the option11–20%, 11 (18%) chose 21–25%, eight (13%) chose26–30% and 12 (19%) chose 30% . Thus the delegates’estimates of pivmecillinam usage in Scandinavia variedwidely, between 5–10% of patients and 30% of patients.The actual usage of pivmecillinam is shown in the Figure.In Scandinavia, between 15% and 30% of patients withacute uncomplicated UTI are treated with pivmecillinam.

Length of treatment for acute uncomplicated lower UTI

Delegates were asked to choose whether the current aver-age length of treatment with co-trimoxazole, ciprofloxacinand fosfomycin trometamol for UTI was 1–3 days, 5–7

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Table I. Antibacterials used (percentage of prescriptions) in the treatment of uncomplicated UTI. Figures are derivedfrom data provided by International Medical Statistics, Pinner, UK

Country

Antibacterial IT ES PT GR FR CH BE DE AT NL UK FI CA

(Fluoro)quinolone 65 73 61 37 57 64 63 30 40 28 7 12 33Trimethoprim 0 0 0 0 0 0 0 1 17 27 56 35 1Co-trimoxazole 5 4 19 17 9 21 5 46 12 10 0 8 34Broad-spectrum penicillin 3 6 8 7 6 5 5 2 8 7 12 1 6Cephalosporin 4 6 3 24 4 2 1 3 10 0 19 6 4Fosfomycin 18 8 2 1 16 5 10 2 8 0 0 2 0Nitrofurantoin 2 1 6 2 7 2 12 9 2 27 6 18 21Pivmecillinam 0 0 1 0 1 0 0 0 1 0 0 16 0Sulphonamide 0 0 0 0 0 0 0 6 0 0 0 0 0Other 3 2 0 12 0 1 4 1 2 1 0 2 1

IT, Italy; ES, Spain; PT, Portugal; GR, Greece; FR, France; CH, Switzerland; BE, Belgium; DE, Germany; AT, Austria; NL, The Netherlands;UK, United Kingdom; FI, Finland; CA, Canada.


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Survey on antibiotic usage in treating UTIs

days, 8–10 days or 11–14 days. As expected, delegatesbelieved that short (3 days) courses of a fluoroquinolone,such as ciprofloxacin, would be used (Table III). Results forfosfomycin, for which single-dose treatment is advocated,were similar (Table III).

Attitudes to the use of fluoroquinolones in acute

uncomplicated lower UTI

After expressing their views concerning appropriate anti-bacterial therapy in uncomplicated UTI and observing data

on the agents actually used, delegates were asked whetherthey felt that the current usage of fluoroquinolones in acuteuncomplicated lower UTI was ‘good’ or ‘bad’ from asocietal perspective, in terms of spread of resistance andimpact on the environment. Seventy-seven (84%) of the

delegates considered the current usage of fluoroquinolonesto be ‘bad’ and 10 (11%) felt it was ‘good’. Five delegates(5%) did not express an opinion.

First-line empirical treatment for acute uncomplicated

lower UTI

At the end of the session, delegates were asked again toselect, from the same choices as previously, the agent theywould recommend as first-line empirical treatment for acuteuncomplicated lower UTI. Thirty-two delegates (35%)chose trimethoprim, 27 (29%) pivmecillinam, 11 (12%)

nitrofurantoin, 10 (11%) co-trimoxazole, two (2%) fluoro-quinolones, two (2%) cephalosporins and eight (9%)‘others’.

Discussion

There was a preponderance of delegates from the Nordiccountries, so the responses may show a bias towards theattitudes of Scandinavian microbiologists and infectiousdisease specialists. The agents recommended by sympo-sium delegates as first-line empirical therapy for acuteuncomplicated lower UTI were trimethoprim, pivmecil-

linam, co-trimoxazole, nitrofurantoin, fluoroquinolonesand cephalosporins. The inclusion of pivmecillinam in this

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Figure. Pivmecillinam usage for uncomplicated UTI in

Norway (— - —), Denmark (- - -) and Sweden (–––).

Table II. Most popular treatments for uncomplicated UTI in western Europe and Canada.a Data were obtained fromInternational Medical Statistics, Pinner, UK

Actual usage

total number of percentage percentage of number (%) of delegatesb

prescriptions change prescriptions for selecting as most widely(103) 1998 to 1999 uncomplicated UTI used treatment for UTI

Norfloxacin 7764 3.9 20.7 16 (18%)Co-trimoxazole 5600 0.4 14.9 35 (39%)Ciprofloxacin 4671 9.8 12.4 16 (18%)Trimethoprim 2807 –2.1 7.5 21 (24%)Fosfomycinc 2833 16.0 7.5Nitrofurantoin 2505 0.8 6.7 1 (1%)Ofloxacinc 1427 –13.1 3.8Pipemidic acidc 1416 –2.1 3.8Amoxycillin clavulanic acidc 1112 –0.9 3.0Lomefloxacinc 887 –15.3 2.4Pivmecillinam no data no data no data 0

aData obtained from Austria, Belgium, Canada, Finland, France, Germany, Greece, Italy, The Netherlands, Portugal, Spain, Switzerland and UK.bEighty-nine of 92 delegates expressed an opinion.cParticipants were not asked to comment on usage of these agents.


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list reflects the above-mentioned bias, as pivmecillinam is

not used in most of Europe.Actual fluoroquinolone use was much greater than mostdelegates expected. There was a general concern amongstparticipants about the amount of fluoroquinolone usage foruncomplicated UTI. Nearly 90% of the microbiologists andinfectious disease clinicans in the survey felt that the levelof current usage was inappropriate from a societal perspec-tive. Although there was general agreement that these areeffective for treating UTI, it was a general view that theseagents were inappropriate first-line treatments, because of the risk of increased resistance, and that they should bereserved for complicated and refractory UTI and pyelo-nephritis.

The general trend towards a shorter duration of therapyfor acute uncomplicated lower UTI5 was endorsed by thissurvey of expert opinion.

The results of the survey were somewhat thought-provoking to participants, particularly regarding whatmany felt was excessive use of fluoroquinolones. This wasapparent when delegates were asked again at the end of thesession to recommend first-line empirical treatment foracute uncomplicated UTI. On the second occasion, therewas an increase in the recommendation of pivmecillinamas a first-line treatment. The number of delegates whorecommended fluoroquinolones for empirical use in UTI

decreased from 10% to 2% after the delegates had seen

data on the actual usage of these agents. This attitude is ingeneral agreement with that of Piddock,6 who recom-mended limited use of fluoroquinolones for first-linetherapy in order to prevent the spread of resistance inpathogenic bacteria.

References

1. Hooton, T. M. (1990). Practice guidelines for urinary tract infec-

tion in the era of managed care. International Journal of Antimicro-

bial Agents 11, 241–5.

2. Warren, J. W., Arbutyn, E., Hebel, J. R., Johnson, J., Schaeffer,

A. J. & Stamm, W. E. (1999). Guidelines for the antimicrobial treat-

ment of uncomplicated acute bacterial cystitis and acutepyelonephritis in women. Clinical Infectious Diseases 29, 745–8.

3. Henning, C. & Bengtsson, L. (1997). The treatment of acute urin-

ary tract problems. Lakartidningen 94, 2387–90.

4. Naber, K. G. (2000). Treatment options for acute uncomplicated

cystitis in adults. Journal of Antimicrobial Chemotherapy 46, Suppl.

1, 23–7.

5. Tice, A. D. (1999). Short-course therapy of acute cystitis: a brief

review of therapeutic strategies. Journal of Antimicrobial Chemo-

therapy 43, Suppl. A, 85–93.

6. Piddock, L. J. V. (1998). Fluoroquinolone resistance. British

Medical Journal 317, 1029–30.

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Table III. Estimated average length of antibiotic treatment in acute cystitis

TreatmentNumber (%) delegates selecting average length of treatment with (days)

duration (days) co-trimoxazolea ciprofloxacinb fosfomycin trometamolc

1–3 29 (36%) 42 (58%) 72 (90%)5–7 48 (60%) 28 (38%) 3 (4%)8–10 3 (4%) 3 (4%) 0 (0%)11–14 0 (0%) 0 (0%) 0 (0%)Others 0 (0%) 0 (0%) 7 (6%)

aEighty of 92 delegates expressed an opinion.bSeventy-three of 92 delegates expressed an opinion.cEighty-two of 92 delegates expressed an opinion.

jac 2000 sup. vigilancia de antibióticos en ivu

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