• Joanna L Langner, Kim F Chiang, and Randall S Stafford.
• Department of Medicine, Stanford University School of Medicine, Stanford, CA. Electronic address: JLangner@Stanford.edu.
• Am. J. Obstet. Gynecol. 2021 Sep 1; 225 (3): 272.e1-272.e11.

BackgroundUncomplicated urinary tract infections are one of the most common bacterial infections in the United States. Clinical practice guidelines from the Infectious Diseases Society of America recommend nitrofurantoin, trimethoprim-sulfamethoxazole, and Fosfomycin as first-line antibiotic treatments and discourage the use of fluoroquinolone antibiotic agents. US Food and Drug Administration released several black box warnings about fluoroquinolones over the past decade owing to antibiotic resistance and a high burden of adverse events. Historically, uncomplicated urinary tract infections have high rates of guideline-discordant treatment with past studies noting substantial use of fluoroquinolones, directly contradicting clinical practice guidelines.ObjectiveThis study aimed to assess the current concordance of physician prescribing practices with Infectious Diseases Society of America guidelines for the treatment of uncomplicated urinary tract infections in women and identify patient and physician predictors of guideline concordance.Study DesignA retrospective observational secondary analysis was conducted using a series of cross-sectional data extracted from the IQVIA (Plymouth Meeting, Pennsylvania) National Disease and Therapeutic Index from 2015 to 2019. An estimated 44.9 million women with uncomplicated urinary tract infections at the age of 18 to 75 years were treated as outpatients. This population was selected to lack relevant comorbidities or urological abnormalities so that it matched the Infectious Diseases Society of America guidelines. The proportion of prescriptions for each antibiotic drug class were reported with 95% confidence intervals and compared with the Infectious Diseases Society of America guidelines. Patient and physician characteristics were included in a multivariate logistic regression model to identify independent predictors of antibiotic selection and thereby guideline concordance.ResultsOf the visits that resulted in antibiotic treatment, the overall concordance rate was 58.4% (26.2 million visits of 44.9 million visits) and increased from 48.2% (3.9 million visits of 8.1 million visits) in 2015 to 64.6% (6.3 million visits of 9.8 million visits) in 2019. The most commonly prescribed antibiotic agents were fluoroquinolones (36.4%, 16.3 million visits of 44.9 million visits), nitrofurantoin (31.8%, 14.3 million visits of 44.9 million visits), and trimethoprim-sulfamethoxazole (26.3%, 11.8 million visits of 44.9 million visits). From 2015 to 2019, fluoroquinolone use decreased whereas nitrofurantoin and beta-lactam use increased. Based on the logistic regression, patients aged 18 to 29 years (odds ratio, 1.60; 95% confidence interval, 1.36-1.88; P<.001) and 30 to 44 years (odds ratio, 1.21; 95% confidence interval, 1.03-1.42; P=.020) had a statistically significantly higher likelihood of receiving guideline-concordant treatment than patients aged 45 to 75 years (reference group). Obstetricians-gynecologists (odds ratio, 3.56; 95% confidence interval, 2.91-4.37; P<.001) and urologists (odds ratio, 3.51; 95% confidence interval, 2.45-5.13; P<.001) had a statistically significantly higher likelihood of concordant treatment than all other specialties combined (reference group).ConclusionGuideline discordance continues in the treatment of uncomplicated urinary tract infections with the overuse of fluoroquinolones and the underuse of first-line antibiotic agents. Although improving, continued misuse of antibiotic agents may contribute to the growing rates of antibiotic resistance. Actions such as educating physicians about antibiotic resistance and clinical practice guidelines and providing feedback on prescription habits are needed to increase guideline concordance and therefore reduce the use of fluoroquinolones, especially for physicians in family and internal medicine.Copyright © 2021 Elsevier Inc. All rights reserved.

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