Antibiotic resistance rates and physician antibiotic prescription patterns of uncomplicated urinary tract infections in southern Chinese primary care

<div><p>Uncomplicated urinary tract infections (UTI) are common in primary care. Whilst primary care physicians are called to be antimicrobial stewards, there is limited primary care antibiotic resistance surveillance and physician antibiotic prescription data available in southern Chinese primary care. The study aimed to investigate the antibiotic resistance rate and antibiotic prescription patterns in female patients with uncomplicated UTI. Factors associated with antibiotic resistance and prescription was explored. A prospective cohort study was conducted in 12 primary care group clinics in Hong Kong of patients presenting with symptoms of uncomplicated UTI from January 2012 to December 2013. Patients’ characteristics such as age, comorbidity, presenting symptoms and prior antibiotic use were recorded by physicians, as well as any empirical antibiotic prescription given at presentation. Urine samples were collected to test for antibiotic resistance of uropathogens. Univariate analysis was conducted to identify factors associated with antibiotic resistance and prescription. A total of 298 patients were included in the study. <i>E</i>. <i>coli</i> was detected in 107 (76%) out of the 141 positive urine samples. Antibiotic resistance rates of <i>E</i>. <i>coli</i> isolates for ampicillin, co-trimoxazole, ciprofloxacin, amoxicillin and nitrofurantoin were 59.8%, 31.8%, 23.4%, 1.9% and 0.9% respectively. <i>E</i>. <i>coli</i> isolates were sensitive to nitrofurantoin (98.1%) followed by amoxicillin (78.5%). The overall physician antibiotic prescription rate was 82.2%. Amoxicillin (39.6%) and nitrofurantoin (28.6%) were the most common prescribed antibiotics. Meanwhile, whilst physicians in public primary care prescribed more amoxicillin (OR: 2.84, 95% CI: 1.67 to 4.85, <i>P</i><0.001) and nitrofurantoin (OR: 2.01, 95% CI: 1.14 to 3.55, <i>P</i> = 0.015), physicians in private clinics prescribed more cefuroxime and ciprofloxacin (<i>P</i><0.05). Matching of antibiotic prescription and antibiotic sensitivity of <i>E</i>. <i>coli</i> isolates occurred in public than private primary care prescriptions (OR: 6.72, 95% CI: 2.07 to 21.80 <i>P</i> = 0.001) and for other uropathogens (OR: 6.19, 95% CI: 1.04 to 36.78 <i>P</i> = 0.034). Mismatching differences of antibiotic prescription and resistance were not evident. In conclusion, nitrofurantoin and amoxicillin should be used as first line antibiotic treatment for uncomplicated UTI. There were significant differences in antibiotic prescription patterns between public and private primary care. Public primary care practitioners were more likely to prescribe first line antibiotic treatment which match antibiotic sensitivity of <i>E</i>. <i>coli</i> isolates and other uropathogens. Further exploration of physician prescribing behaviour and educational interventions, particularly in private primary care may helpful. Meanwhile, development and dissemination of guidelines for primary care management of uncomplicated UTI as well as continued surveillance of antibiotic resistance and physician antibiotic prescription is recommended.</p></div

Patients’ characteristics (n = 298).

<p>Patients’ characteristics (n = 298).</p

Flow chart of the patient’s recruitment process and analysis of their urine samples.

<p>Flow chart of the patient’s recruitment process and analysis of their urine samples.</p

Antibiotic prescription and uropathogen sensitivity and resistance.

<p>Antibiotic prescription and uropathogen sensitivity and resistance.</p

Antibiotic prescription rate among patients (n = 245).

<p>Antibiotic prescription rate among patients (n = 245).</p

Odds ratio of patients’ characteristics and resistance to antibiotic agents (n = 107).

<p>Odds ratio of patients’ characteristics and resistance to antibiotic agents (n = 107).</p

Susceptibility profile of <i>E</i>. <i>coli</i>, other uropathogens, ESBL producing isolates.

<p>Susceptibility profile of <i>E</i>. <i>coli</i>, other uropathogens, ESBL producing isolates.</p

Additional file 1 of Optimizing the frequency of physician encounters in follow - up care for patients with type 2 diabetes mellitus: a systematic review

Additional file 1: Supplementary Figure 1. Summary of risk of bias assessment for the included studies Randomized controlled trials (assessed by the Cochrane RoB2 tool). Supplementary Figure 2. Histogram plot for the findings in the sensitivity analysis after excluding the studies without specifying the type of diabetes1