Yet some of the impetus for ordering heavyweight compounds also comes from patients, he says. While urinary tract bacteria might not notice the difference between Bactrim and Cipro, the health care system certainly does. In other words, with 2. If that's not a sufficient deterrent to follow the infection society's recommendations, Huang says failure to do so may ultimately make treating UTIs far more difficult. Spreading the burden of killing the disease-causing bacteria over several drugs promotes resistance to each of them concurrently.
A better approach, and the one experts advise, is to use a single drug -- in this case Bactrim -- until it works no more. James R. Johnson, a University of Minnesota physician who helped write the UTI treatment guidelines, says bugs resistant to Bactrim and its near relatives have become more common. So the increase in prescriptions for other drugs isn't necessarily concerning. On the other hand, he adds, "it would be a mistake" if doctors were offering their patients stronger medications without knowing they were infected with resistant organisms.
Johnson considers the surge in fluoroquinolone use particularly alarming, since losing these drugs to resistance would be a major setback for infection control in general. As a result, he says, it's probably wiser to use nitrofurantoin as the runner-up to Bactrim for urinary infections. You can also visit the UrologyChannel. Acquire the license to the best health content in the world. Study: Doctors favor pricey drugs over cheaper, first-line one.
Johnson, M. Are You at Risk for Pancreatic Cysts? Physician's Briefing Weekly Coronavirus Roundup. American College of Surgeons, Oct. Related articles. Trending topics. These data suggest that trimethoprim-sulfamethoxazole may no longer be appropriate as an empiric therapy in certain geographic areas. In these areas, initial empiric outpatient therapy with a fluoroquinolone should be strongly considered. Patients treated with trimethoprim-sulfamethoxazole should be followed up carefully until susceptibility results are available.
A frequent practice in emergency departments is to administer the first antimicrobial dose intravenously to sicker patients with pyelonephritis, particularly those with nausea and vomiting. Ceftriaxone was chosen as most representative of emergency department practice at that time based on an informal survey. Administration of the first antimicrobial dose intravenously did not generally appear to enhance cure rates compared with those observed in patients receiving only oral regimens.
However, patients were not randomized to these treatment strategies and, therefore, no conclusions can be made as to their relative therapeutic benefit. We also evaluated the use of health care resources by women presumptively treated for acute pyelonephritis with the 2 antimicrobial regimens. This trial was not powered to show statistical significance in the economic differences between treatment groups for health care resource use.
However, resource use did appear to be higher in all categories among trimethoprim-sulfamethoxazole—treated patients, with the exception of radiological procedures. Although the prescription cost of the ciprofloxacin regimen was greater than that of the trimethoprim-sulfamethoxazole regimen, patients treated with the trimethoprim-sulfamethoxazole regimen tended to have greater overall costs, particularly those related to subsequent hospitalizations, office visits, and laboratory tests.
It should be noted that, because these results were derived from a clinical trial, they may not accurately reflect actual or optimal practice. For example, whereas some physicians may routinely change antimicrobial drug therapy for an improved patient whose urine isolate is subsequently found to demonstrate in vitro resistance to their treatment drug, this was not mandated in our protocol.
Also, since the cost analysis was conducted from the perspective of the third-party payer, our results did not capture indirect or intangible costs eg, missed work or school, diminished health-related quality of life.
The current investigation was designed to address many of the limitations of previous studies and to conform to the Infectious Diseases Society of America's recommendations for conducting clinical trials by limiting the study population to a homogeneous group of young women with acute uncomplicated pyelonephritis; by employing a randomized blinded design; by treating all women, including those later found to have resistant strains with the assigned regimen; by following patients for approximately 4 to 6 weeks; and by enrolling an adequate sample size to ensure statistical power.
We intended the clinical response to be judged independently of bacteriologic outcome by the treating physician, but the physicians did have access to culture and susceptibility results.
Therefore, assessment of the clinical outcome, and subsequent management, could have been influenced by this knowledge. In conclusion, for the outcomes of bacteriologic and clinical cure, we have demonstrated that the 7-day ciprofloxacin regimen is at least as efficacious as the day trimethoprim-sulfamethoxazole regimen, and statistically, the ciprofloxacin regimen was superior. In practice, the shorter duration ciprofloxacin regimen, which was associated with fewer adverse effects, would be expected to lead to higher patient acceptance and medication compliance rates.
The higher cost of the ciprofloxacin prescription would have to be weighed against the potential additional costs related to more treatment failures with trimethoprim-sulfamethoxazole, especially in geographic areas with high rates of E coli resistance to trimethoprim-sulfamethoxazole. These findings should not be extrapolated to men, patients with complicated infections, or those with severe sepsis. Patients with acute uncomplicated pyelonephritis should have urine cultures obtained to both confirm the diagnosis and assess the antimicrobial susceptibility of the infecting uropathogen, so as to better predict bacteriologic and clinical outcome.
Continued local and national surveillance of uropathogen antimicrobial-resistance patterns is essential to provide optimal care for women with acute uncomplicated pyelonephritis in an era of increasing antimicrobial resistance. Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy Continue.
Figure 1. The ciprofloxacin group was given oral ciprofloxacin, mg twice per day for 7 days with or without initial mg intravenous dose followed by placebo for 7 days. Figure 2. The ciprofloxacin group was given an oral dose of ciprofloxacin, mg twice per day for 7 days with or without initial mg intravenous dose followed by placebo for 7 days.
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Points to Consider. Guidelines for antimicrobial therapy of uncomplicated acute bacterial cystitis and acute pyelonephritis in women. Clin Infect Dis. Therapy for women hospitalized with acute pyelonephritis. Acute renal infection in women. Ann Intern Med. Pyelonephritis in adult women. Am J Med. Abraham E, Baraff LJ. Oral versus parenteral therapy of pyelonephritis. Curr Ther Res. Treatment of pyelonephritis in an observation unit. Ann Emerg Med. Comparison of ciprofloxacin with netilmicin for the treatment of acute pyelonephritis.
One or three week's treatment of acute pyelonephritis? Acta Med Scand. Therapy of symptomatic pyelonephritis in women. J Urol. Failure of excessive doses of ampicillin to prevent bacterial relapse in the treatment of acute pyelonephritis. Beunders AJ. Development of antibacterial resistance: the Dutch experience. J Antimicrob Chemother. Five-year survey of changing patterns of susceptibility of bacterial uropathogens to trimethoprim-sulfamethoxazole and other antimicrobial agents.
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David A. Talan, MD ; Walter E. Stamm, MD ; Thomas M. Hooton, MD ; et al Gregory J. Church, MD. Continuing Medical Education. Study Population.
Study Procedures. Microbiological Methods. Main Outcome Measures. Health Resource Use and Cost Analyses.
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