The relationship between primary care antibiotic prescribing and bacterial resistance in adults in the community: A controlled observational study using individual patient data
To examine the relationship between primary care prescribed antibiotics and the development of antibiotic resistance in perineal flora contaminating unselected urinary isolates from a large sample of asymptomatic adults representative of the general community.
Escherichia coli isolates contaminating urine samples were obtained from asymptomatic adults aged >16 years registered with general practices in the former Avon and Gloucestershire health authority areas. Data on antibiotic exposure during the 12 months prior to providing the urine samples were collected from the primary care electronic and paper medical records. The main outcome measure was resistance to amoxicillin or trimethoprim or both.
Two thousand nine hundred and forty-three adults submitted urine samples. Susceptibility among E. coli isolates and antibiotic prescribing data were available from 618 patients. We found no evidence of an association between resistance and patients' exposure to any antibiotic prescribed in primary care in the previous 12 months [adjusted odds ratio (OR) 1.12, 95% confidence interval 0.77-1.65, P = 0.52]. Secondary analyses demonstrated greater resistance in patients exposed to antibiotics within 2 months (adjusted OR 1.95, 1.08-3.49, P = 0.03), a dose-response relationship to increasing exposure to trimethoprim in the previous 12 months (adjusted OR 1.01, 1.01-1.02, P = 0.001) and that individuals who had been prescribed any beta-lactam antibiotic in the previous 12 months had amoxicillin MICs more than twice (adjusted 95% CI 1.23-3.31, P = 0.009) that of those who had not been prescribed any beta-lactams.
Whether or not adults receive a prescription for any antibiotic during a 12 month period does not appear to influence the antimicrobial resistance of perineal flora. However, the temporal and dose-response relationships found may be suggestive of a causative association and should be the focus of further research.
Available from: Céire Costelloe
- "A 10% data attrition rate was assumed owing to withheld consent to examine medical records and unlinked or missing prescribing and resistance data, giving a total of 2970 samples, of which up to 148 would be MRSA. With respect to the first research question, a previous investigation  found that 6% of patients had received a ␤-lactam, macrolide or quinolone antibiotic within 2 months. Assuming that 3% of those participants who were MSSA colonised received at least one ␤-lactam, macrolide or quinolone antibiotic prescription in the 2 months prior to nasal swab submission and a ratio of MSSA participants to MRSA participants of 19:1, the study had >80% power to detect an absolute difference in antibiotic exposure of six percentage points [equivalent to an odds ratio (OR) of 3.2] with a 5% two-sided ␣. "
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ABSTRACT: The objectives of this study were to investigate the relationship between primary care antibiotics prescribed within 2 months and 12 months and the carriage of meticillin-resistant Staphylococcus aureus (MRSA) in nasal flora from a large representative sample of community-resident adults. S. aureus isolates were obtained from nasal samples submitted by UK resident adults aged ≥ 16 years registered with 12 general practices in the former Avon and Gloucestershire health authority areas. Individual-level antibiotic exposure data during the 12 months prior to providing the samples were collected from the primary care electronic records. MRSA status was determined by measuring resistance to cefoxitin. In total, 6937 adults were invited to take part, of whom 5917 returned a nasal sample. S. aureus was identified in 946 samples and a total of 761 participants consented to primary care record review and had complete data for the analyses. There was no evidence of an association between any antibiotic in the previous 2 months and MRSA isolation, with an adjusted odds ratio (aOR) of 1.33 [95% confidence interval (CI) 0.12-15; P=0.8]. There was a suggestion of an association between any antibiotic use in the previous 12 months and MRSA, with an aOR of 2.45 (95% CI 0.95-6.3; P=0.06). In conclusion, there is a suggestion that antibiotics prescribed within 12 months is associated with the carriage of MRSA, but not within 2 months, although the 2-month analysis had fewer data subjects and was therefore underpowered to detect this association. A larger study would be able to clarify these associations further.
Available from: Akke Vellinga
- "An observational study recruited 288 patients from 9 practices and required the GP to enrol patients and patients to fill out a questionnaire  and obtained 60% response and 39% subsequent participation. A prospective study with two recruitment arms obtained 66% participation for patients approached within the healthcare facility and 41% participation in a random sample of non attending patients . In a spotter practice model, clinicians from three general practices were asked to submit mid-stream urine samples from all patients presenting with symptoms suggestive of UTI . "
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Urinary tract infections (UTIs) are the second most common bacterial infections in general practice and a frequent indication for prescription of antimicrobials. Increasing concern about the association between the use of antimicrobials and acquired antimicrobial resistance has highlighted the need for rational pharmacotherapy of common infections in general practice.
Management of urinary tract infections in general practice was studied prospectively over 8 weeks. Patients presenting with suspected UTI submitted a urine sample and were enrolled with an opt-out methodology. Data were collected on demographic variables, previous antimicrobial use and urine samples. Appropriateness of different treatment scenarios was assessed by comparing treatment with the laboratory report of the urine sample.
A total of 22 practices participated in the study and included 866 patients. Bacteriuria was established for 21% of the patients, pyuria without bacteriuria for 9% and 70% showed no laboratory evidence of UTI. An antimicrobial agent was prescribed to 56% (481) of the patients, of whom 33% had an isolate, 11% with pyuria only and 56% without laboratory evidence of UTI. When taking all patients into account, 14% patients had an isolate identified and were prescribed an antimicrobial to which the isolate was susceptible. The agents most commonly prescribed for UTI were co-amoxyclav (33%), trimethoprim (26%) and fluoroquinolones (17%). Variation between practices in antimicrobial prescribing as well as in their preference for certain antimicrobials, was observed. Treatment as prescribed by the GP was interpreted as appropriate for 55% of the patients. Three different treatment scenarios were simulated, i.e. if all patients who received an antimicrobial were treated with nitrofurantoin, trimethoprim or ciprofloxacin only. Treatment as prescribed by the GP was no more effective than treatment with nitrofurantoin for all patients given an antimicrobial or treatment with ciprofloxacin in all patients. Prescribing cost was lower for nitrofurantoin. Empirical treatment of all patients with trimethoprim only was less effective due to the higher resistance levels.
There appears to be considerable scope to reduce the frequency and increase the quality of antimicrobial prescribing for patients with suspected UTI.
Available from: Ana Cristina Gales
- "Effective management of UTIs in the outpatient setting has been hampered by the fact that many strains have developed resistance to several oral antimicrobial agents. The increasing frequency of thrimetoprim/ sulfamethoxazole (TMP-SMX) resistance is worrisome, since this agent is frequently prescribed for uncomplicated UTIs in many developed and developing countries (Talan et al. 2000, Hay et al. 2005, Sader et al. 2005). Reports from North America indicate an elevated prevalence of TMP-SMX-resistant isolates in this region associated with increased clinical failure rates (Manges et al. 2004). "
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ABSTRACT: Emerging resistance phenotypes and antimicrobial resistance rates among pathogens recovered from community-acquired urinary tract infections (CA-UTI) is an increasing problem in specific regions, limiting therapeutic options. As part of the SENTRY Antimicrobial Surveillance Program, a total of 611 isolates were collected in 2003 from patients with CA-UTI presenting at Latin American medical centers. Each strain was tested in a central laboratory using Clinical Laboratory Standard Institute (CLSI) broth microdilution methods with appropriate controls. Escherichia coli was the leading pathogen (66%), followed by Klebsiella spp. (7%), Proteus mirabilis (6.4%), Enterococcus spp. (5.6%), and Pseudomonas aeruginosa (4.6%). Surprisingly high resistance rates were recorded for E. coli against first-line orally administered agents for CA-UTI, such as ampicillin (53.6%), TMP/SMX (40.4%), ciprofloxacin (21.6%), and gatifloxacin (17.1%). Decreased susceptibility rates to TMP/SMX and ciprofloxacin were also documented for Klebsiella spp. (79.1 and 81.4%, respectively), and P. mirabilis (71.8 and 84.6%, respectively). For Enterococcus spp., susceptibility rates to ampicillin, chloramphenicol, ciprofloxacin, and vancomycin were 88.2, 85.3, 55.9, and 97.1%, respectively. High-level resistance to gentamicin was detected in 24% of Enterococcus spp. Bacteria isolated from patients with CA-UTI in Latin America showed limited susceptibility to orally administered antimicrobials, especially for TMP/SMX and fluoroquinolones. Our results highlight the need for developing specific CA-UTI guidelines in geographic regions where elevated resistance to new and old compounds may influence prescribing decisions.
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