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Antibiotic Switch After Treatment with UTI Antibiotics in Male Patients

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Antibiotic Switch After Treatment with UTI Antibiotics in Male Patients Infectious Diseases ISSN: 2374-4235 (Print) 2374-4243 (Online) Journal homepage: https://www.tandfonline.com/loi/infd20 Antibiotic switch after treatment with UTI antibiotics in male patients Marius A. H. Skow, Ingvild Vik & Sigurd Høye To cite this article: Marius A. H. Skow, Ingvild Vik & Sigurd Høye (2020) Antibiotic switch after treatment with UTI antibiotics in male patients, Infectious Diseases, 52:6, 405-412, DOI: 10.1080/23744235.2020.1736329 To link to this article: https://doi.org/10.1080/23744235.2020.1736329 © 2020 The Author(s). Published by Informa View supplementary material UK Limited, trading as Taylor & Francis Group. Published online: 14 Mar 2020. Submit your article to this journal Article views: 1747 View related articles View Crossmark data Citing articles: 2 View citing articles Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=infd20 INFECTIOUS DISEASES, https://doi.org/10.1080/23744235.2020.1736329 2020; VOL. 52, NO. 6, 405–412 ORIGINAL ARTICLE Antibiotic switch after treatment with UTI antibiotics in male patients Marius A. H. Skow, Ingvild Vik and Sigurd Høye The Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway ABSTRACT Background: There is a lack of evidence on treatment of urinary tract infections (UTIs) in male patients in a primary care setting, and whether narrow-spectrum antibiotics are safe and effective. Objectives: To explore antibiotic switch rates after treatment with UTI antibiotics in men over the last 11 years. Material: We analysed data from the Norwegian Prescription Database (NorPD). Men 16 years receiving cefalexin, cipro- floxacin, cotrimoxazole, nitrofurantoin, ofloxacin, pivmecillinam or trimethoprim during the period 2008–2018 were included. Antibiotic switch was defined as being prescribed a different antibiotic drug appropriate for UTI within 14 days after initial treatment. We calculated rates of antibiotic switch and corresponding odds ratios for each antibiotic drug. Results: Seven hundred twenty-six thousand and ninety-six (726,096) prescriptions to 429,807 men were defined as pos- sible UTI episodes. Fluoroquinolones, pivmecillinam and cotrimoxazole were most frequently prescribed. Forty-nine thou- sand five hundred and thirty-one (49,531) (6.8%) of the treatments resulted in antibiotic switch. Compared to cotrimoxazole, the risk of antibiotic switch was higher for pivmecillinam (OR: 2.46; 95% CI, 2.39–2.53) and trimethoprim (OR: 2.12; 95% CI, 2.04–2.20), and lower for fluoroquinolones (OR: 0.40; 95% CI, 0.39–0.42) and cefalexin (OR: 0.28; 95% CI, 0.26–0.30). Treatment duration of 7 days and age of 50 years were associated with an increased risk of antibiotic switch. Conclusion: Fluoroquinolones and cefalexin were associated with lower antibiotic switch rates than the recommended UTI antibiotics (pivmecillinam, nitrofurantoin and trimethoprim). However, the rates of antibiotic switch following treatment of male patients with first-line empirical UTI antibiotics are relatively low, indicating that the current guidelines are safe. KEYWORDS ARTICLE HISTORY CONTACT Primary health care Received 11 November 2019 Marius A. H. Skow anti-bacterial agents Revised 10 February 2020 [email protected] urinary tract infections Accepted 23 February 2020 The Antibiotic Centre for Primary Care, treatment failure Department of General Practice, Institute of male Health and Society, University of Oslo, Oslo, Norway Supplemental data for this article can be accessed here. ß 2020 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way. 406 M. A. H. SKOW ET AL. Introduction secrecy requirements (ref 2018/2496/REK sør-øst C). Data protection was approved by the Norwegian centre for Antibiotic resistance in common organisms is an increas- Research Data (NSD number: 796958). The study proto- ing global concern, and the need to reduce over-use of col was approved by the Norwegian Prescription antibiotics is evident [1]. In Norway, approximately 84% Database (ref 19/10717). The study was conducted in of all antibiotics for human treatment are prescribed in accordance with the Declaration of Helsinki, as well as primary health care [2]. Urinary tract infections (UTIs) are national and institutional standards. among the most common infections treated with antibi- otics in general practice in Norway, estimated to account for almost 25% of all antibiotic prescriptions in Setting and design general practice [2,3]. Approximately, 20% of all UTIs We analysed data from the Norwegian Prescription occur in men [4,5]. The incidence of UTI in the commu- Database (NorPD), a national electronic database with a – nity is estimated to 0.9 2.4 cases per 1000 men below complete listing of all prescription drugs dispensed by the age of 55 years, increasing with age to levels at or pharmacies in Norway since 2004 [20]. In Norway, all above 7.7 per 1000 men of 85 years and older [4,6,7]. antibiotics are available by prescription only, and the Traditionally, UTIs are categorised as uncomplicated or database contains information on drugs dispensed to complicated infections [8]. It is common practice to treat all patients in ambulatory care, that is, general practice, UTIs in male patients as complicated infections, and most out-of-hours services and outpatient treatment in spe- international guidelines recommend fluoroquinolones or tri- cialist health services. The NorPD covers the entire – methoprim-sulfamethoxazole (cotrimoxazole) for 7 14 days Norwegian population (5,328,212 inhabitants per 1 [9,10]. Randomised trials have shown that 14 days of cipro- January 2019). Each prescription record contains a floxacin is favourable to both 7 days and 28 days in male unique anonymised person-identifier, age, sex, munici- patients with a febrile UTI [11,12]. However, there are on- pality, full account of the dispensed product, the dis- going discussions regarding the safety and efficacy of treat- pensed quantity and the date of purchase. The NorPD ing acute cystitis in male patients as uncomplicated UTIs contains diagnosis codes (ICD-10 or ICPC2) only for pre- [13]. Some newer studies suggest that men with acute scriptions given through the general reimbursement – cystitis do not need treatment for more than 5 7days programme for chronic conditions (The Blue Prescription – [14 16], and others argue that nitrofurantoin or pivmecilli- Programme). The database does not contain information nam are appropriate as empirical treatment options [17,18]. on signs, symptoms or diagnosis for patients receiving In Norway, the current treatment guidelines recom- standard non-reimbursed prescriptions. mend treating acute cystitis in male patients empirically From the NorPD database, we extracted all prescrip- with nitrofurantoin, pivmecillinam or trimethoprim for tions of cefalexin, ciprofloxacin, cotrimoxazole, fosfomycin, – 5 7 days, whereas at-risk patients or men with suspected nitrofurantoin, ofloxacin, pivmecillinam, sulfadiazine and pyelonephritis or prostatitis should be treated with cotri- trimethoprim to male patients in the period January 2008 – moxazole or ciprofloxacin for 7 14 days [19]. The lack of to December 2018. We decided not to include amoxicillin evidence calls for studies investigating how to effectively in our study as it is not recommended for UTI treatment treat male patients with acute cystitis in general practice. in the national guidelines, and it is more frequently used The aim of this study was to explore the rates of anti- to treat respiratory tract infections [19]. Patients were eli- biotic switch as a proxy for treatment failure in men gible for inclusion if they were male and 16 years old receiving antibiotic treatment appropriate for UTI in the when the prescription was dispensed. Patients treated last 11 years, and to investigate whether the rate of anti- with fosfomycin or sulfadiazine were excluded, as the biotic switch varied between different antibiotic treat- drugs are infrequently used in Norway. The DDDs used in ments. A secondary aim was to describe the prescription the dataset were according to the ATC/DDD index of patterns in the study period. 2019 [21]. For population statistics, we used Norwegian population data from Statistics Norway (SSB) [22]. Materials and methods Ethics Identification of UTI episodes The Regional Committee for Medical and Health For each individual, we identified a UTI episode as a pre- Research Ethics granted a dispensation from professional scription of a UTI antibiotic, defined as cefalexin, INFECTIOUS DISEASES 407 cotrimoxazole, fluoroquinolones (ciprofloxacin or ofloxa- Table 1. Total UTI antibiotic prescriptions to men 16 years in – cin), nitrofurantoin, pivmecillinam or trimethoprim. To Norway 2008 2018. Age DDD be defined as a UTI episode, prescriptions had to con- Antibiotic Prescriptions Patients Mean (SD) Median (IQR) tain a sufficient quantity and dosage, with cut-offs at Cotrimoxazole 308,358 155,794 61.6 (17.7) 7.5 (5.0–10.0) minimum two DDD and maximum 14 DDD. We did not Cefalexin 88,298 60,419 53.4 (19.4) 5.0 (5.0–10.0) Fluoroquinolones 468,111 238,515 59.9 (17.8) 10.0 (5.0–10.0) include prescriptions if there were more than one anti- Nitrofurantoin 93,605 37,771 70.4 (15.5) 6.3 (6.3–12.5) Pivmecillinam 377,036 174,360 67.3 (17.4) 10.0 (6.7–13.3) biotic prescription on the same day. As a measure to Trimethoprim 180,470 84,241 68.8 (17.1) 5.6 (5.3–7.5) identify “new” infections and to avoid prophylactic treat- Total 1,515,878 476,423 63.4 (18.1) 10.0 (5.6–10.0) ment, we only included prescriptions if the patient had at least 90 days without treatment with the relevant antibiotics.
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