Predicting Antibiotic Susceptibility Among Patients With Recurrent Urinary Tract Infection Using a Prior Culture
Abstract
Purpose:
Recurrent cystitis guidelines recommend relying on a local antibiogram or prior urine culture to guide empirical prescribing, yet little data exist to quantify the predictive value of a prior culture. We constructed a urinary antibiogram and evaluated test metrics (sensitivity, specificity, and Bayes’ positive and negative predictive values) of a prior gram-negative organism on predicting subsequent resistance or susceptibility among patients with uncomplicated, recurrent cystitis.
Materials and Methods:
We performed a retrospective database study of adults with recurrent, uncomplicated cystitis (cystitis occurring 2 times in 6 months or 3 times in 12 months) from urology or primary care clinics between November 1, 2016, and December 31, 2018. We excluded pregnant females, patients with complicated cystitis, or pyelonephritis. Test metrics were calculated between sequential, paired cultures using standard formulas.
Results:
We included 597 visits from 232 unique patients wherein 310 (51.2%) visits had a urine culture and 165 had gram-negative uropathogens isolated. Patients with gram-negative uropathogens were mostly females (97%), with a median age of 58.5 years. Our antibiogram found 38.0%, 27.9%, and 5.5% of Escherichia coli isolates had resistance to trimethoprim-sulfamethoxazole, ciprofloxacin, and nitrofurantoin, respectively. Prior cultures (within 2 years) had good predictive value for detecting future susceptibility to first-line agents nitrofurantoin (0.85) and trimethoprim-sulfamethoxazole (0.78) and excellent predictive values (≥0.90) for cefepime, ceftriaxone, cefuroxime, ciprofloxacin, levofloxacin, gentamicin, tobramycin, piperacillin-tazobactam, and imipenem.
Conclusions:
Considerable antibiotic resistance was detected among E coli isolates in patients with recurrent, uncomplicated cystitis. Using a prior culture as a guide can enhance the probability of selecting an effective empirical agent.
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Support: This investigator-initiated research study was funded by Rebiotix, a Ferring Company. M.V.K is supported in part by the Health Resources and Services Administration, an agency of the US Department of Health and Human Services (grant no. T32 HP10031). B.W.T. is supported in part by the US Department of Veterans Affairs Health Services Research and Development Service (grant no. CIN 13-413) at the Center for Innovations in Quality, Effectiveness, and Safety.
Conflict of Interest Disclosures: The Authors have no conflicts of interest to disclose.
Ethics Statement: This study received Institutional Review Board approval (IRB no. H-46627).
Author Contributions: All Authors have fulfilled the 4 criteria set forth for authorship by the International Committee of Medical Journal Editors.
Data Availability: The data sets generated during and/or analyzed during the current study are not publicly available due to patient confidentiality, but a de-identified data set is available from the corresponding author on reasonable request.
Disclaimer: The contents do not represent the views of VA or the United States Government.
Editor's Note: This article is the fourth of 5 published in this issue for which Category 1 CME credits can be earned. Instructions for obtaining credits are given with the questions on pages 201 and 202.
