• Aaron Brant, Patrick Lewicki, Xian Wu, Christina Sze, Jeffrey P Johnson, Lee Ponsky, Keith S Kaye, Gilbert J Wise, and Jonathan E Shoag.
• Department of Urology, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA. aab9038@med.cornell.edu.
• J Gen Intern Med. 2024 Jun 1; 39 (8): 141414221414-1422.

BackgroundThe FDA issued a "black box" warning regarding risks of fluoroquinolones in 2008 with updates in 2011, 2013, and 2016.ObjectiveTo examine antimicrobial use in hospital-treated UTIs from 2000 to 2020.DesignCross-sectional study with interrupted time series analysis.ParticipantsPatient encounters with a diagnosis of UTI from January 2000 to March 2020, excluding diagnoses of renal abscess, chronic cystitis, and infection of the gastrointestinal tract, lungs, or prostate.Main MeasuresMonthly use of fluoroquinolone and non-fluoroquinolone antibiotics were assessed. Fluoroquinolone resistance was assessed in available cultures. Interrupted time series analysis examined level and trend changes of antimicrobial use with each FDA label change.Key ResultsA total of 9,950,790 patient encounters were included. From July 2008 to March 2020, fluoroquinolone use declined from 61.7% to 11.7%, with similar negative trends observed in inpatients and outpatients, age ≥ 60 and < 60 years, males and females, patients with and without pyelonephritis, and across physician specialties. Ceftriaxone use increased from 26.4% encounters in July 2008 to 63.6% of encounters in March 2020. Among encounters with available culture data, fluoroquinolone resistance declined by 28.9% from 2009 to 2020. On interrupted time series analysis, the July 2008 FDA warning was associated with a trend change (-0.32%, < 0.001) and level change (-5.02%, p < 0.001) in monthly fluoroquinolone use.ConclusionsDuring this era of "black box" warnings, there was a decline in fluoroquinolone use for hospital-treated UTI with a concomitant decline in fluoroquinolone resistance and rise in ceftriaxone use. Efforts to restrict use of a medication class may lead to compensatory increases in use of a single alternative agent with changes in antimicrobial resistance profiles.© 2023. The Author(s), under exclusive licence to Society of General Internal Medicine.

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