Assessment of Fluoroquinolone Appropriateness for Hospitalized Patients with Asymptomatic Bacteriuria and Cystitis: A Multi-Hospital Cohort Study

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Open Forum Infectious Diseases



Fluoroquinolones increase the risk of Clostridioides difficile infection and antibiotic resistance, but are frequently used for hospitalized patients with bacteriuria. We assessed patterns and predictors of inappropriate fluoroquinolone (FQ) use among hospitalized patients with asymptomatic bacteriuria (ASB) and cystitis. Methods

This is a retrospective cohort study of non-ICU medicine patients with ASB or cystitis (complicated or uncomplicated) from January 2018 to March 2019 at 43 Michigan hospitals. Patients with concomitant infections, bacteremia, or pyelonephritis were excluded. Each day of FQ (ciprofloxacin, levofloxacin) use (inpatient and post discharge) was assessed for appropriateness. FQ use was inappropriate if: (A) ASB, (B) urine culture with an FQ-resistant bacteria, (C) a safer alternative empiric or definitive antibiotic (treatment ≥2 days after urine culture collection) based on disease severity, cultures, allergies, and renal function, or (D) excess duration (>7 days complicated cystitis; >3 days uncomplicated cystitis). Hospitals were also surveyed on existing stewardship (ASP) practices targeting FQ use. ASP practices associated with inappropriate FQ use were evaluated using logistic generalized estimated equation models adjusting for patient factors and hospital clustering. Results

Of 4849 included patients with ASB (39.7%) or cystitis (60.3%), 21.9% (n = 1,061) received an FQ and 92.7% (n = 984) received a, FQ inappropriately (Figure 1). Of 5,465 FQ days of therapy (DOT), 90.7% (n = 4,959) were inappropriate. Definitive treatment of complicated cystitis led to the greatest proportion of inappropriate FQ DOTs (50.6%), followed by ASB (36.4%) (Table 1). Hospitals varied (Figure 2), but those with cascade reporting of antibiotic susceptibilities, urinary tract infection (UTI) treatment guideline or an ASP performing prospective audit and feedback on FQ use had lower inappropriate FQ treatment rates (Table 2). Conclusion

Hospitalized patients with ASB and cystitis often receive an FQ. Most FQ use is inappropriate due to ASB treatment or FQ use for complicated cystitis despite the option of an alternative antibiotic. Prospective audit and feedback, UTI guidelines, and cascade reporting of antibiotic susceptibilities can be used by ASP to reduce inappropriate FQ use.




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