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Laura Galatti, Aurelio Sessa, Giampiero Mazzaglia, Serena Pecchioli, Alessandro Rossi, Claudio Cricelli, Gian Carlo Schito, Giuseppe Nicoletti, Achille P. Caputi, Antibiotic prescribing for acute and recurrent cystitis in primary care: a 4 year descriptive study, Journal of Antimicrobial Chemotherapy, Volume 57, Issue 3, March 2006, Pages 551–556, https://doi.org/10.1093/jac/dkl008
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Abstract
Objectives: To explore the antibiotic prescribing pattern for cystitis and the patient-related variables associated with prescription during a 4 year period among Italian general practitioners (GPs).
Methods: We obtained information from the ‘Health Search Database’ (HSD), an Italian general practice research database. From a total sample of 457 672 eligible patients aged >16 years registered up to December 2002, we included those whose diagnoses could be classified as acute (uncomplicated and complicated) and recurrent cystitis. Patients' features and prevalence of antibiotic users were assessed.
Results: Of 35 129 cases diagnosed during the period 1999–2002, 96.0% of them were acute cystitis (39.2% recorded as uncomplicated). The prevalence of cases with acute complicated and uncomplicated cystitis slightly increased during the 4 year period, whereas it remained stable for recurrent cystitis. Most of the cystitis cases reported no diagnostic tests. More than 70% of patients were prescribed with at least one antibiotic, with a 4-fold increased risk of antibiotic use for acute cystitis throughout the study period. The prevalence of antibiotic users reached 86.2% for both acute uncomplicated and complicated cystitis in 2002, and 81.5% for recurrent cystitis. Fluoroquinolones represented the most common antibiotics being prescribed although they markedly decreased during these years. Fosfomycin trometamol use increased dramatically, becoming the first choice for any type of cystitis.
Conclusions: Data indicate an evident rise in antibiotic use mostly related to fosfomycin trometamol. They also indicate that such a prescriptive trend finds confirmation from the available evidence for acute uncomplicated cystitis, although the management of recurrent cystitis could be further improved.
Introduction
Urinary tract infections (UTIs) are among the most prevalent infectious diseases and the most common bacterial infections in woman, being associated with substantial morbidity.1–3 Half of all women will have at least one episode of acute cystitis during their adult life and one-quarter will also report recurrent episodes.4 In the USA, UTIs are responsible for over 7 million physician visits annually and for over one-third of all hospital-acquired infections, whereas in Italy the perceived prevalence of UTIs among the general practitioners (GPs) is 1.7% ambulatory-related patients/GP/month.1,5 Acute cystitis should be considered uncomplicated if patients are not pregnant or elders, and in the absence of either recent instrumentation or antimicrobial treatment or functional and anatomic abnormalities of the genitourinary tract.6 On the other hand, complicated UTI occurs in men or women of all ages with structural, metabolic or functional abnormalities of the genitourinary tract.4,7 Finally, a recurrent urinary tract infection is a symptomatic UTI that follows clinical resolution of an earlier UTI generally, but not necessarily, after treatment.8 Management of cystitis is not an easy task and, in selecting the most appropriate antimicrobial treatment, the antibiotic resistance represents the most important factor. Most of these infections are caused by Escherichia coli and its resistance to some of the most commonly used agents is increasing. Therefore, an appropriate knowledge of the current bacterial resistance is essential for optimal management of cystitis.9 Because of the central role of GPs in the management of this disease, the aim of this study was to explore the antibiotic prescribing pattern and the patient-related variables associated with prescription for acute and recurrent cystitis during a 4 year period among Italian physicians.
Methods
Data source
We obtained information from the ‘Health Search Database’ (HSD), an Italian general practice research database that comprises the complete electronic medical records of all patients registered in the lists of participating physicians. Characteristics of the database have been described in previous studies.10,11 Briefly, the HSD contains patient demographic details, medical records (e.g. diagnoses, tests and tests results, hospitalization, etc.), drug history and prevention records. A unique identification number links all data for an individual patient in an anonymous way and no identifying details are available. All participating physicians had to use specially designed software allowing them to register all the disease episodes once and to link any medical intervention to the recorded disease. Data are subject to a range of quality checks. Any variations within agreed ranges are investigated and submitted to each participating physician. GPs who fail to meet standard quality criteria are not considered for epidemiological studies.12 At the time this study was initiated, 320 GPs were considered up to standard.
Study population
The dynamic cohort included all patients alive and permanently registered in the lists of the participating physicians, who visited the GPs' offices during the years 1999–2002 and provided information for at least 1 year prior to entry into the study. Therefore, from a total of 270 626 eligible patients (58.6% of total registered patients) visiting the GPs' offices in the year 1999, we reached a cumulative sample of 457 672 (99.1%) at the end of the study period, with no significant variations in the patient demographics throughout the years. Such evidence is consistent with previous research conducted in the USA, demonstrating that GPs see ∼65% of their patients in 1 year and 95% in 3 years.13
We then selected those patients aged >16 years whose diagnoses could be classified as acute or recurrent cystitis (ICD-9 595), either according to the International Classification of Diseases (ICD-9) or according to an encoded medical evaluation.14 Finally, to distinguish between uncomplicated and complicated acute cystitis, we identified as complicated: male patients, females older than 50 years, patients with diagnosis related to particular conditions (e.g. pregnancy or diabetes) or those specifically recorded as acute complicated cystitis.
For each selected case, demographic (age, gender, geographic area) and clinical features (severity health status according to the Charlson co-morbidity index) were assessed.15 We were unable to adjust for illness severity as this information is not available in the HSD. However, we evaluated the general health status of each patient using the Charlson co-morbidity index which assesses the co-morbidities taking into account the number of concomitant conditions and their severity. The use of diagnostic tests was attributed to a specific diagnosis if recorded within 30 days from the date of diagnosis.
Statistical analysis
For each type of cystitis, the extent of antibiotic use was calculated by dividing the number of treated infections with the total number of diagnosed infections. Since the geographic distribution of cystitis cases changed throughout the years (Northern Italy: 30.7%; Central Italy: 14.3%; Southern Italy: 55.0% in 1999 versus Northern Italy: 36.9%; Central Italy: 17.9%; Southern Italy: 45.2% in 2002), we have taken into account such variation because previous studies demonstrated wide variability in antibiotic use across Italy.16 Therefore, multivariate unconditional logistic regressions were performed to assess adjusted odds ratios (ORs) of the effect of patients' characteristics on antibiotic use. A frequency analysis was also conducted for each of the considered outcomes, by type of cystitis and by the other patient variables.
To explore the antibiotic prescribing patterns in the treatment of cystitis, we assessed the prevalence of individual antibiotic users, ranked by extent of use in the year 2002 and adjusted by geographic location. Statistical analyses were performed using STATA 7.0 (STATA Corporation, TX, USA).
Results
A total of 35 129 cases were recorded by participant physicians during the period 1999–2002, and 96.0% of them were diagnosed with acute cystitis (39.2% uncomplicated cystitis). The main features of the study sample are described in Table 1. The prevalence of cases with acute uncomplicated and complicated cystitis slightly increased during the 4 year period, whereas the estimate was stable for the recurrent type. For recurrent cystitis, females accounted for >80% of the total being slightly higher than the acute complicated type (69.9%). The most common diagnostic test performed was urine culture and antibiogram, although in most of the cases no diagnostic tests were performed. At least one antibiotic prescription was performed in >70% cases, with a higher prevalence for acute complicated and recurrent cystitis (79.1 and 81.1%, respectively). Table 2 reports the proportion of antibiotic use and the associated variables. From 1999 to 2002 the risk of antibiotic use showed a 4-fold increase, particularly for acute uncomplicated cystitis (59.3% in 1999 versus 86.2% in 2002) and acute complicated cystitis (63.0% in 1999 versus 86.2% in 2002), whereas for recurrent cystitis a non-significant increase was reported. Patients aged >65 years were more likely to receive antibiotics in both acute complicated cystitis (OR: 1.63; 95% CI: 1.43–1.86) and recurrent cystitis (OR: 1.96; 95% CI: 1.39–2.76), as well as patients with more severe health status, particularly in acute cystitis. Conversely, the use of diagnostic tests strongly decreased the risk of antibiotic prescription for any type of cystitis. Geographic location was significantly associated with a decreased risk only in Southern Italy, compared with Northern Italy, for acute uncomplicated (OR: 0.88; 95% CI: 0.80–0.97) and complicated cystitis (OR: 0.91; 95% CI: 0.84–0.99).
Patients' characteristics . | Acute uncomplicated cystitis (n = 13 223) . | Acute complicated cystitis (n = 20 503) . | Recurrent cystitis (n = 1403) . | |||
---|---|---|---|---|---|---|
Females | 13 223 (100) | 14 331 (69.9) | 1244 (88.7) | |||
Mean age (± SD) | 35.3 ± 8.8 | 64.6 ± 14.9 | 62.5 ± 18.9 | |||
Age groups | ||||||
17–45 | 11 219 (84.8) | 2013 (9.8) | 315 (22.5) | |||
46–65 | 2004 (15.2) | 8224 (40.1) | 341 (24.3) | |||
>65 | – | 10 266 (50.1) | 747 (53.2) | |||
Geographic areas | ||||||
Northern Italy | 4422 (33.4) | 6798 (33.1) | 467 (33.3) | |||
Central Italy | 2180 (16.5) | 3770 (18.4) | 220 (15.7) | |||
Southern Italy | 6621 (50.1) | 9935 (48.5) | 716 (51.0) | |||
Charlson index | ||||||
0 | 11 285 (85.3) | 13 100 (63.9) | 959 (68.4) | |||
1–2 | 1560 (11.8) | 4955 (24.2) | 332 (23.7) | |||
3–4 | 236 (1.8) | 1187 (5.8) | 53 (3.8) | |||
≥5 | 142 (1.1) | 1261 (6.1) | 59 (4.2) | |||
Diagnostic testsa | ||||||
None | 9814 (74.2) | 15 650 (76.3) | 1030 (73.4) | |||
Urine culture + antibiogram | 2122 (16.0) | 3153 (15.4) | 242 (17.2) | |||
Culture exams | 1314 (9.9) | 1710 (8.3) | 127 (9.1) | |||
Antibiogram | 93 (0.7) | 164 (0.8) | 26 (1.9) | |||
Antibody test and hybridization | 89 (0.7) | 149 (0.7) | 20 (1.4) | |||
Cystoscopy | 4 (0.03) | 22 (0.1) | 5 (0.4) | |||
Radiographic exams | 7 (0.1) | 17 (0.1) | 3 (0.2) | |||
Years (% of total eligible patients)b | ||||||
1999 | 1399 (0.5) | 2235 (0.8) | 269 (0.1) | |||
2000 | 3200 (0.9) | 5077 (1.4) | 504 (0.1) | |||
2001 | 4403 (1.0) | 6644 (1.5) | 365 (0.1) | |||
2002 | 4221 (0.9) | 6547 (1.4) | 265 (0.1) | |||
Antibiotic users (% of total cases) | 10 200 (77.1) | 16 213 (79.1) | 1138 (81.1) |
Patients' characteristics . | Acute uncomplicated cystitis (n = 13 223) . | Acute complicated cystitis (n = 20 503) . | Recurrent cystitis (n = 1403) . | |||
---|---|---|---|---|---|---|
Females | 13 223 (100) | 14 331 (69.9) | 1244 (88.7) | |||
Mean age (± SD) | 35.3 ± 8.8 | 64.6 ± 14.9 | 62.5 ± 18.9 | |||
Age groups | ||||||
17–45 | 11 219 (84.8) | 2013 (9.8) | 315 (22.5) | |||
46–65 | 2004 (15.2) | 8224 (40.1) | 341 (24.3) | |||
>65 | – | 10 266 (50.1) | 747 (53.2) | |||
Geographic areas | ||||||
Northern Italy | 4422 (33.4) | 6798 (33.1) | 467 (33.3) | |||
Central Italy | 2180 (16.5) | 3770 (18.4) | 220 (15.7) | |||
Southern Italy | 6621 (50.1) | 9935 (48.5) | 716 (51.0) | |||
Charlson index | ||||||
0 | 11 285 (85.3) | 13 100 (63.9) | 959 (68.4) | |||
1–2 | 1560 (11.8) | 4955 (24.2) | 332 (23.7) | |||
3–4 | 236 (1.8) | 1187 (5.8) | 53 (3.8) | |||
≥5 | 142 (1.1) | 1261 (6.1) | 59 (4.2) | |||
Diagnostic testsa | ||||||
None | 9814 (74.2) | 15 650 (76.3) | 1030 (73.4) | |||
Urine culture + antibiogram | 2122 (16.0) | 3153 (15.4) | 242 (17.2) | |||
Culture exams | 1314 (9.9) | 1710 (8.3) | 127 (9.1) | |||
Antibiogram | 93 (0.7) | 164 (0.8) | 26 (1.9) | |||
Antibody test and hybridization | 89 (0.7) | 149 (0.7) | 20 (1.4) | |||
Cystoscopy | 4 (0.03) | 22 (0.1) | 5 (0.4) | |||
Radiographic exams | 7 (0.1) | 17 (0.1) | 3 (0.2) | |||
Years (% of total eligible patients)b | ||||||
1999 | 1399 (0.5) | 2235 (0.8) | 269 (0.1) | |||
2000 | 3200 (0.9) | 5077 (1.4) | 504 (0.1) | |||
2001 | 4403 (1.0) | 6644 (1.5) | 365 (0.1) | |||
2002 | 4221 (0.9) | 6547 (1.4) | 265 (0.1) | |||
Antibiotic users (% of total cases) | 10 200 (77.1) | 16 213 (79.1) | 1138 (81.1) |
The number of diagnostic tests is more than total cases because each case could have performed more than one test.
HSD patients during 1999: 270 626, during 2000: 367 701, during 2001: 430 374, during 2002: 457 672.
Patients' characteristics . | Acute uncomplicated cystitis (n = 13 223) . | Acute complicated cystitis (n = 20 503) . | Recurrent cystitis (n = 1403) . | |||
---|---|---|---|---|---|---|
Females | 13 223 (100) | 14 331 (69.9) | 1244 (88.7) | |||
Mean age (± SD) | 35.3 ± 8.8 | 64.6 ± 14.9 | 62.5 ± 18.9 | |||
Age groups | ||||||
17–45 | 11 219 (84.8) | 2013 (9.8) | 315 (22.5) | |||
46–65 | 2004 (15.2) | 8224 (40.1) | 341 (24.3) | |||
>65 | – | 10 266 (50.1) | 747 (53.2) | |||
Geographic areas | ||||||
Northern Italy | 4422 (33.4) | 6798 (33.1) | 467 (33.3) | |||
Central Italy | 2180 (16.5) | 3770 (18.4) | 220 (15.7) | |||
Southern Italy | 6621 (50.1) | 9935 (48.5) | 716 (51.0) | |||
Charlson index | ||||||
0 | 11 285 (85.3) | 13 100 (63.9) | 959 (68.4) | |||
1–2 | 1560 (11.8) | 4955 (24.2) | 332 (23.7) | |||
3–4 | 236 (1.8) | 1187 (5.8) | 53 (3.8) | |||
≥5 | 142 (1.1) | 1261 (6.1) | 59 (4.2) | |||
Diagnostic testsa | ||||||
None | 9814 (74.2) | 15 650 (76.3) | 1030 (73.4) | |||
Urine culture + antibiogram | 2122 (16.0) | 3153 (15.4) | 242 (17.2) | |||
Culture exams | 1314 (9.9) | 1710 (8.3) | 127 (9.1) | |||
Antibiogram | 93 (0.7) | 164 (0.8) | 26 (1.9) | |||
Antibody test and hybridization | 89 (0.7) | 149 (0.7) | 20 (1.4) | |||
Cystoscopy | 4 (0.03) | 22 (0.1) | 5 (0.4) | |||
Radiographic exams | 7 (0.1) | 17 (0.1) | 3 (0.2) | |||
Years (% of total eligible patients)b | ||||||
1999 | 1399 (0.5) | 2235 (0.8) | 269 (0.1) | |||
2000 | 3200 (0.9) | 5077 (1.4) | 504 (0.1) | |||
2001 | 4403 (1.0) | 6644 (1.5) | 365 (0.1) | |||
2002 | 4221 (0.9) | 6547 (1.4) | 265 (0.1) | |||
Antibiotic users (% of total cases) | 10 200 (77.1) | 16 213 (79.1) | 1138 (81.1) |
Patients' characteristics . | Acute uncomplicated cystitis (n = 13 223) . | Acute complicated cystitis (n = 20 503) . | Recurrent cystitis (n = 1403) . | |||
---|---|---|---|---|---|---|
Females | 13 223 (100) | 14 331 (69.9) | 1244 (88.7) | |||
Mean age (± SD) | 35.3 ± 8.8 | 64.6 ± 14.9 | 62.5 ± 18.9 | |||
Age groups | ||||||
17–45 | 11 219 (84.8) | 2013 (9.8) | 315 (22.5) | |||
46–65 | 2004 (15.2) | 8224 (40.1) | 341 (24.3) | |||
>65 | – | 10 266 (50.1) | 747 (53.2) | |||
Geographic areas | ||||||
Northern Italy | 4422 (33.4) | 6798 (33.1) | 467 (33.3) | |||
Central Italy | 2180 (16.5) | 3770 (18.4) | 220 (15.7) | |||
Southern Italy | 6621 (50.1) | 9935 (48.5) | 716 (51.0) | |||
Charlson index | ||||||
0 | 11 285 (85.3) | 13 100 (63.9) | 959 (68.4) | |||
1–2 | 1560 (11.8) | 4955 (24.2) | 332 (23.7) | |||
3–4 | 236 (1.8) | 1187 (5.8) | 53 (3.8) | |||
≥5 | 142 (1.1) | 1261 (6.1) | 59 (4.2) | |||
Diagnostic testsa | ||||||
None | 9814 (74.2) | 15 650 (76.3) | 1030 (73.4) | |||
Urine culture + antibiogram | 2122 (16.0) | 3153 (15.4) | 242 (17.2) | |||
Culture exams | 1314 (9.9) | 1710 (8.3) | 127 (9.1) | |||
Antibiogram | 93 (0.7) | 164 (0.8) | 26 (1.9) | |||
Antibody test and hybridization | 89 (0.7) | 149 (0.7) | 20 (1.4) | |||
Cystoscopy | 4 (0.03) | 22 (0.1) | 5 (0.4) | |||
Radiographic exams | 7 (0.1) | 17 (0.1) | 3 (0.2) | |||
Years (% of total eligible patients)b | ||||||
1999 | 1399 (0.5) | 2235 (0.8) | 269 (0.1) | |||
2000 | 3200 (0.9) | 5077 (1.4) | 504 (0.1) | |||
2001 | 4403 (1.0) | 6644 (1.5) | 365 (0.1) | |||
2002 | 4221 (0.9) | 6547 (1.4) | 265 (0.1) | |||
Antibiotic users (% of total cases) | 10 200 (77.1) | 16 213 (79.1) | 1138 (81.1) |
The number of diagnostic tests is more than total cases because each case could have performed more than one test.
HSD patients during 1999: 270 626, during 2000: 367 701, during 2001: 430 374, during 2002: 457 672.
. | Acute uncomplicated cystitis . | . | Acute complicated cystitis . | . | Recurrent cystitis . | . | ||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Variables . | Number (% of total infections) . | Adjusted OR (95% CI) . | Number (% of total infections) . | Adjusted OR (95% CI) . | Number (% of total infections) . | Adjusted OR (95% CI) . | ||||||
Gendera | ||||||||||||
Males | – | – | 4639 (75.2) | 1.00 | 124 (78.0) | 1.00 | ||||||
Females | 10 200 (77.1) | – | 11 574 (80.8) | 1.16 (1.06–1.27) | 1014 (81.5) | 1.43 (0.94–2.18) | ||||||
Age groupsa | ||||||||||||
17–45 | 8627 (76.9) | 1.00 | 1382 (68.7) | 1.00 | 233 (74.0) | 1.00 | ||||||
46–65 | 1573 (78.5) | 1.09 (0.84–1.23) | 6518 (79.3) | 1.52 (1.34–1.74) | 266 (78.0) | 1.20 (0.83–1.74) | ||||||
>65 | – | – | 8313 (81.0) | 1.63 (1.43–1.86) | 639 (85.5) | 1.96 (1.39–2.76) | ||||||
Geographic areas | ||||||||||||
Northern Italy | 3452 (78.1) | 1.00 | 5456 (80.3) | 1.00 | 375 (80.3) | 1.00 | ||||||
Central Italy | 1704 (78.2) | 0.96 (0.84–1.10) | 2995 (79.4) | 0.91 (0.82–1.01) | 169 (76.8) | 0.81 (0.54–1.20) | ||||||
Southern Italy | 5044 (76.2) | 0.88 (0.80–0.97) | 7762 (78.1) | 0.91 (0.84–0.99) | 594 (83.0) | 1.27 (0.93–1.73) | ||||||
Charlson index | ||||||||||||
0 | 8575 (76.4) | 1.00 | 10 064 (77.3) | 1.00 | 753 (79.6) | 1.00 | ||||||
1–2 | 1293 (81.0) | 1.16 (1.01–1.33) | 4095 (82.0) | 1.15 (1.05–1.26) | 289 (84.8) | 1.17 (0.82–1.66) | ||||||
>3 | 332 (83.6) | 1.40 (1.05–1.85) | 2054 (82.3) | 1.15 (1.02–1.29) | 96 (82.8) | 1.08 (0.63–1.83) | ||||||
Diagnostic tests | ||||||||||||
No | 7945 (80.9) | 1.00 | 12 934 (82.7) | 1.00 | 856 (83.1) | 1.00 | ||||||
Yes | 2255 (66.2) | 0.41 (0.38.0.45) | 3279 (67.6) | 0.40 (0.37–0.43) | 282 (75.6) | 0.68 (0.50–0.91) | ||||||
Years | ||||||||||||
1999 | 830 (59.3) | 1.00 | 1408 (63.0) | 1.00 | 209 (77.7) | 1.00 | ||||||
2000 | 2030 (63.4) | 1.27 (1.11–1.45) | 3561 (70.1) | 1.50 (1.35–1.68) | 398 (79.0) | 1.08 (0.75–1.55) | ||||||
2001 | 3701 (84.1) | 3.92 (3.42–4.49) | 5601 (84.3) | 3.48 (3.11–3.89) | 315 (86.0) | 1.94 (1.27–2.97) | ||||||
2002 | 3639 (86.2) | 4.66 (4.04–5.37) | 5643 (86.2) | 4.08 (3.64–4.58) | 216 (81.5) | 1.36 (0.88–2.11) |
. | Acute uncomplicated cystitis . | . | Acute complicated cystitis . | . | Recurrent cystitis . | . | ||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Variables . | Number (% of total infections) . | Adjusted OR (95% CI) . | Number (% of total infections) . | Adjusted OR (95% CI) . | Number (% of total infections) . | Adjusted OR (95% CI) . | ||||||
Gendera | ||||||||||||
Males | – | – | 4639 (75.2) | 1.00 | 124 (78.0) | 1.00 | ||||||
Females | 10 200 (77.1) | – | 11 574 (80.8) | 1.16 (1.06–1.27) | 1014 (81.5) | 1.43 (0.94–2.18) | ||||||
Age groupsa | ||||||||||||
17–45 | 8627 (76.9) | 1.00 | 1382 (68.7) | 1.00 | 233 (74.0) | 1.00 | ||||||
46–65 | 1573 (78.5) | 1.09 (0.84–1.23) | 6518 (79.3) | 1.52 (1.34–1.74) | 266 (78.0) | 1.20 (0.83–1.74) | ||||||
>65 | – | – | 8313 (81.0) | 1.63 (1.43–1.86) | 639 (85.5) | 1.96 (1.39–2.76) | ||||||
Geographic areas | ||||||||||||
Northern Italy | 3452 (78.1) | 1.00 | 5456 (80.3) | 1.00 | 375 (80.3) | 1.00 | ||||||
Central Italy | 1704 (78.2) | 0.96 (0.84–1.10) | 2995 (79.4) | 0.91 (0.82–1.01) | 169 (76.8) | 0.81 (0.54–1.20) | ||||||
Southern Italy | 5044 (76.2) | 0.88 (0.80–0.97) | 7762 (78.1) | 0.91 (0.84–0.99) | 594 (83.0) | 1.27 (0.93–1.73) | ||||||
Charlson index | ||||||||||||
0 | 8575 (76.4) | 1.00 | 10 064 (77.3) | 1.00 | 753 (79.6) | 1.00 | ||||||
1–2 | 1293 (81.0) | 1.16 (1.01–1.33) | 4095 (82.0) | 1.15 (1.05–1.26) | 289 (84.8) | 1.17 (0.82–1.66) | ||||||
>3 | 332 (83.6) | 1.40 (1.05–1.85) | 2054 (82.3) | 1.15 (1.02–1.29) | 96 (82.8) | 1.08 (0.63–1.83) | ||||||
Diagnostic tests | ||||||||||||
No | 7945 (80.9) | 1.00 | 12 934 (82.7) | 1.00 | 856 (83.1) | 1.00 | ||||||
Yes | 2255 (66.2) | 0.41 (0.38.0.45) | 3279 (67.6) | 0.40 (0.37–0.43) | 282 (75.6) | 0.68 (0.50–0.91) | ||||||
Years | ||||||||||||
1999 | 830 (59.3) | 1.00 | 1408 (63.0) | 1.00 | 209 (77.7) | 1.00 | ||||||
2000 | 2030 (63.4) | 1.27 (1.11–1.45) | 3561 (70.1) | 1.50 (1.35–1.68) | 398 (79.0) | 1.08 (0.75–1.55) | ||||||
2001 | 3701 (84.1) | 3.92 (3.42–4.49) | 5601 (84.3) | 3.48 (3.11–3.89) | 315 (86.0) | 1.94 (1.27–2.97) | ||||||
2002 | 3639 (86.2) | 4.66 (4.04–5.37) | 5643 (86.2) | 4.08 (3.64–4.58) | 216 (81.5) | 1.36 (0.88–2.11) |
Columns show numbers with relative frequencies (%) and multivariate adjusted odd ratios (OR) with 95% confidence intervals (CI).
Because of the definition of acute uncomplicated cystitis the patients included in this group were only females aged ≤50.
. | Acute uncomplicated cystitis . | . | Acute complicated cystitis . | . | Recurrent cystitis . | . | ||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Variables . | Number (% of total infections) . | Adjusted OR (95% CI) . | Number (% of total infections) . | Adjusted OR (95% CI) . | Number (% of total infections) . | Adjusted OR (95% CI) . | ||||||
Gendera | ||||||||||||
Males | – | – | 4639 (75.2) | 1.00 | 124 (78.0) | 1.00 | ||||||
Females | 10 200 (77.1) | – | 11 574 (80.8) | 1.16 (1.06–1.27) | 1014 (81.5) | 1.43 (0.94–2.18) | ||||||
Age groupsa | ||||||||||||
17–45 | 8627 (76.9) | 1.00 | 1382 (68.7) | 1.00 | 233 (74.0) | 1.00 | ||||||
46–65 | 1573 (78.5) | 1.09 (0.84–1.23) | 6518 (79.3) | 1.52 (1.34–1.74) | 266 (78.0) | 1.20 (0.83–1.74) | ||||||
>65 | – | – | 8313 (81.0) | 1.63 (1.43–1.86) | 639 (85.5) | 1.96 (1.39–2.76) | ||||||
Geographic areas | ||||||||||||
Northern Italy | 3452 (78.1) | 1.00 | 5456 (80.3) | 1.00 | 375 (80.3) | 1.00 | ||||||
Central Italy | 1704 (78.2) | 0.96 (0.84–1.10) | 2995 (79.4) | 0.91 (0.82–1.01) | 169 (76.8) | 0.81 (0.54–1.20) | ||||||
Southern Italy | 5044 (76.2) | 0.88 (0.80–0.97) | 7762 (78.1) | 0.91 (0.84–0.99) | 594 (83.0) | 1.27 (0.93–1.73) | ||||||
Charlson index | ||||||||||||
0 | 8575 (76.4) | 1.00 | 10 064 (77.3) | 1.00 | 753 (79.6) | 1.00 | ||||||
1–2 | 1293 (81.0) | 1.16 (1.01–1.33) | 4095 (82.0) | 1.15 (1.05–1.26) | 289 (84.8) | 1.17 (0.82–1.66) | ||||||
>3 | 332 (83.6) | 1.40 (1.05–1.85) | 2054 (82.3) | 1.15 (1.02–1.29) | 96 (82.8) | 1.08 (0.63–1.83) | ||||||
Diagnostic tests | ||||||||||||
No | 7945 (80.9) | 1.00 | 12 934 (82.7) | 1.00 | 856 (83.1) | 1.00 | ||||||
Yes | 2255 (66.2) | 0.41 (0.38.0.45) | 3279 (67.6) | 0.40 (0.37–0.43) | 282 (75.6) | 0.68 (0.50–0.91) | ||||||
Years | ||||||||||||
1999 | 830 (59.3) | 1.00 | 1408 (63.0) | 1.00 | 209 (77.7) | 1.00 | ||||||
2000 | 2030 (63.4) | 1.27 (1.11–1.45) | 3561 (70.1) | 1.50 (1.35–1.68) | 398 (79.0) | 1.08 (0.75–1.55) | ||||||
2001 | 3701 (84.1) | 3.92 (3.42–4.49) | 5601 (84.3) | 3.48 (3.11–3.89) | 315 (86.0) | 1.94 (1.27–2.97) | ||||||
2002 | 3639 (86.2) | 4.66 (4.04–5.37) | 5643 (86.2) | 4.08 (3.64–4.58) | 216 (81.5) | 1.36 (0.88–2.11) |
. | Acute uncomplicated cystitis . | . | Acute complicated cystitis . | . | Recurrent cystitis . | . | ||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Variables . | Number (% of total infections) . | Adjusted OR (95% CI) . | Number (% of total infections) . | Adjusted OR (95% CI) . | Number (% of total infections) . | Adjusted OR (95% CI) . | ||||||
Gendera | ||||||||||||
Males | – | – | 4639 (75.2) | 1.00 | 124 (78.0) | 1.00 | ||||||
Females | 10 200 (77.1) | – | 11 574 (80.8) | 1.16 (1.06–1.27) | 1014 (81.5) | 1.43 (0.94–2.18) | ||||||
Age groupsa | ||||||||||||
17–45 | 8627 (76.9) | 1.00 | 1382 (68.7) | 1.00 | 233 (74.0) | 1.00 | ||||||
46–65 | 1573 (78.5) | 1.09 (0.84–1.23) | 6518 (79.3) | 1.52 (1.34–1.74) | 266 (78.0) | 1.20 (0.83–1.74) | ||||||
>65 | – | – | 8313 (81.0) | 1.63 (1.43–1.86) | 639 (85.5) | 1.96 (1.39–2.76) | ||||||
Geographic areas | ||||||||||||
Northern Italy | 3452 (78.1) | 1.00 | 5456 (80.3) | 1.00 | 375 (80.3) | 1.00 | ||||||
Central Italy | 1704 (78.2) | 0.96 (0.84–1.10) | 2995 (79.4) | 0.91 (0.82–1.01) | 169 (76.8) | 0.81 (0.54–1.20) | ||||||
Southern Italy | 5044 (76.2) | 0.88 (0.80–0.97) | 7762 (78.1) | 0.91 (0.84–0.99) | 594 (83.0) | 1.27 (0.93–1.73) | ||||||
Charlson index | ||||||||||||
0 | 8575 (76.4) | 1.00 | 10 064 (77.3) | 1.00 | 753 (79.6) | 1.00 | ||||||
1–2 | 1293 (81.0) | 1.16 (1.01–1.33) | 4095 (82.0) | 1.15 (1.05–1.26) | 289 (84.8) | 1.17 (0.82–1.66) | ||||||
>3 | 332 (83.6) | 1.40 (1.05–1.85) | 2054 (82.3) | 1.15 (1.02–1.29) | 96 (82.8) | 1.08 (0.63–1.83) | ||||||
Diagnostic tests | ||||||||||||
No | 7945 (80.9) | 1.00 | 12 934 (82.7) | 1.00 | 856 (83.1) | 1.00 | ||||||
Yes | 2255 (66.2) | 0.41 (0.38.0.45) | 3279 (67.6) | 0.40 (0.37–0.43) | 282 (75.6) | 0.68 (0.50–0.91) | ||||||
Years | ||||||||||||
1999 | 830 (59.3) | 1.00 | 1408 (63.0) | 1.00 | 209 (77.7) | 1.00 | ||||||
2000 | 2030 (63.4) | 1.27 (1.11–1.45) | 3561 (70.1) | 1.50 (1.35–1.68) | 398 (79.0) | 1.08 (0.75–1.55) | ||||||
2001 | 3701 (84.1) | 3.92 (3.42–4.49) | 5601 (84.3) | 3.48 (3.11–3.89) | 315 (86.0) | 1.94 (1.27–2.97) | ||||||
2002 | 3639 (86.2) | 4.66 (4.04–5.37) | 5643 (86.2) | 4.08 (3.64–4.58) | 216 (81.5) | 1.36 (0.88–2.11) |
Columns show numbers with relative frequencies (%) and multivariate adjusted odd ratios (OR) with 95% confidence intervals (CI).
Because of the definition of acute uncomplicated cystitis the patients included in this group were only females aged ≤50.
Tables 3, 4 and 5 show the prevalence of distinct antibiotic users for the different types of cystitis during the years 1999–2002. Fluoroquinolones represented the most commonly used therapeutic class, being prescribed in 40.1% of patients with uncomplicated cystitis, 47.9% with complicated cystitis and 49.1% with recurrent cystitis, although a decreasing trend was reported during the years.
. | Years (no. of acute uncomplicated cystitis cases) . | . | . | . | . | . | . | . | |||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
. | 1999 (n = 1399) . | . | 2000 (n = 3200) . | . | 2001 (n = 4403) . | . | 2002 (n = 4221) . | . | |||||||
Antibiotics . | No. of users . | % (95% CI) . | No. of users . | % (95% CI) . | No. of users . | % (95% CI) . | No. of users . | % (95% CI) . | |||||||
Fosfomycin trometamol | 74 | 5.3 (4.1–6.5) | 81 | 2.5 (2.0–3.1) | 1154 | 26.2 (24.9–27.5) | 1425 | 33.8 (32.3–35.2) | |||||||
Ciprofloxacin | 378 | 27.0 (24.7–29.4) | 422 | 13.2 (12.0–14.4) | 532 | 12.1 (11.1–13.0) | 542 | 12.8 (11.8–13.8) | |||||||
Norfloxacin | 562 | 40.1 (37.2–42.7) | 673 | 21.0 (19.6–22.4) | 640 | 14.5 (13.5–15.6) | 499 | 11.8 (10.8–12.8) | |||||||
Levofloxacin | 99 | 7.1 (5.7–8.5) | 220 | 6.9 (6.0–7.8) | 289 | 6.6 (5.8–7.3) | 368 | 8.7 (7.8–9.6) | |||||||
Trimethoprim/sulfamethoxazole | 320 | 22.9 (20.6–25.1) | 235 | 7.3 (6.4–8.3) | 280 | 6.4 (5.6–7.1) | 277 | 6.6 (5.8–7.3) | |||||||
Pipemidic acid | 9 | 0.7 (0.2–1.2) | 15 | 0.5 (0.2–0.7) | 213 | 4.8 (4.2–5.5) | 207 | 4.9 (4.2–5.5) | |||||||
Amoxicillin+clavulanic acid | 74 | 5.3 (4.1–6.5) | 101 | 3.2 (2.5–3.8) | 123 | 2.8 (2.3–3.3) | 126 | 3.0 (2.4–3.5) | |||||||
Pefloxacin | 123 | 8.8 (7.3–10.3) | 143 | 4.5 (3.7–5.2) | 159 | 3.6 (3.0–4.2) | 124 | 2.9 (2.4–3.4) | |||||||
Lomefloxacin | 193 | 13.8 (12.0–15.7) | 177 | 5.5 (4.7–6.3) | 132 | 3.0 (2.5–3.5) | 123 | 2.9 (2.4–3.4) | |||||||
Nitrofurantoin | 3 | 0.2 (0.04–0.6) | 3 | 0.1 (0.01–0.2) | 49 | 1.1 (0.8–1.4) | 69 | 1.6 (1.2–2.0) | |||||||
Amoxicillin | 71 | 5.1 (3.9–6.3) | 63 | 2.0 (1.5–2.5) | 58 | 1.3 (1.0–1.6) | 67 | 1.6 (1.2–2.0) | |||||||
Cinoxacin | 8 | 0.6 (0.2–1.1) | 5 | 0.1 (0.05–0.3) | 35 | 0.8 (0.5–1.1) | 46 | 1.1 (0.7–1.4) | |||||||
Others | 267 | 19.1 (17.0–21.2) | 270 | 8.4 (7.4–9.4) | 284 | 6.5 (5.7–7.2) | 251 | 5.9 (5.2–6.7) |
. | Years (no. of acute uncomplicated cystitis cases) . | . | . | . | . | . | . | . | |||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
. | 1999 (n = 1399) . | . | 2000 (n = 3200) . | . | 2001 (n = 4403) . | . | 2002 (n = 4221) . | . | |||||||
Antibiotics . | No. of users . | % (95% CI) . | No. of users . | % (95% CI) . | No. of users . | % (95% CI) . | No. of users . | % (95% CI) . | |||||||
Fosfomycin trometamol | 74 | 5.3 (4.1–6.5) | 81 | 2.5 (2.0–3.1) | 1154 | 26.2 (24.9–27.5) | 1425 | 33.8 (32.3–35.2) | |||||||
Ciprofloxacin | 378 | 27.0 (24.7–29.4) | 422 | 13.2 (12.0–14.4) | 532 | 12.1 (11.1–13.0) | 542 | 12.8 (11.8–13.8) | |||||||
Norfloxacin | 562 | 40.1 (37.2–42.7) | 673 | 21.0 (19.6–22.4) | 640 | 14.5 (13.5–15.6) | 499 | 11.8 (10.8–12.8) | |||||||
Levofloxacin | 99 | 7.1 (5.7–8.5) | 220 | 6.9 (6.0–7.8) | 289 | 6.6 (5.8–7.3) | 368 | 8.7 (7.8–9.6) | |||||||
Trimethoprim/sulfamethoxazole | 320 | 22.9 (20.6–25.1) | 235 | 7.3 (6.4–8.3) | 280 | 6.4 (5.6–7.1) | 277 | 6.6 (5.8–7.3) | |||||||
Pipemidic acid | 9 | 0.7 (0.2–1.2) | 15 | 0.5 (0.2–0.7) | 213 | 4.8 (4.2–5.5) | 207 | 4.9 (4.2–5.5) | |||||||
Amoxicillin+clavulanic acid | 74 | 5.3 (4.1–6.5) | 101 | 3.2 (2.5–3.8) | 123 | 2.8 (2.3–3.3) | 126 | 3.0 (2.4–3.5) | |||||||
Pefloxacin | 123 | 8.8 (7.3–10.3) | 143 | 4.5 (3.7–5.2) | 159 | 3.6 (3.0–4.2) | 124 | 2.9 (2.4–3.4) | |||||||
Lomefloxacin | 193 | 13.8 (12.0–15.7) | 177 | 5.5 (4.7–6.3) | 132 | 3.0 (2.5–3.5) | 123 | 2.9 (2.4–3.4) | |||||||
Nitrofurantoin | 3 | 0.2 (0.04–0.6) | 3 | 0.1 (0.01–0.2) | 49 | 1.1 (0.8–1.4) | 69 | 1.6 (1.2–2.0) | |||||||
Amoxicillin | 71 | 5.1 (3.9–6.3) | 63 | 2.0 (1.5–2.5) | 58 | 1.3 (1.0–1.6) | 67 | 1.6 (1.2–2.0) | |||||||
Cinoxacin | 8 | 0.6 (0.2–1.1) | 5 | 0.1 (0.05–0.3) | 35 | 0.8 (0.5–1.1) | 46 | 1.1 (0.7–1.4) | |||||||
Others | 267 | 19.1 (17.0–21.2) | 270 | 8.4 (7.4–9.4) | 284 | 6.5 (5.7–7.2) | 251 | 5.9 (5.2–6.7) |
Geographic distribution of acute uncomplicated cystitis cases in the year 2002.
. | Years (no. of acute uncomplicated cystitis cases) . | . | . | . | . | . | . | . | |||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
. | 1999 (n = 1399) . | . | 2000 (n = 3200) . | . | 2001 (n = 4403) . | . | 2002 (n = 4221) . | . | |||||||
Antibiotics . | No. of users . | % (95% CI) . | No. of users . | % (95% CI) . | No. of users . | % (95% CI) . | No. of users . | % (95% CI) . | |||||||
Fosfomycin trometamol | 74 | 5.3 (4.1–6.5) | 81 | 2.5 (2.0–3.1) | 1154 | 26.2 (24.9–27.5) | 1425 | 33.8 (32.3–35.2) | |||||||
Ciprofloxacin | 378 | 27.0 (24.7–29.4) | 422 | 13.2 (12.0–14.4) | 532 | 12.1 (11.1–13.0) | 542 | 12.8 (11.8–13.8) | |||||||
Norfloxacin | 562 | 40.1 (37.2–42.7) | 673 | 21.0 (19.6–22.4) | 640 | 14.5 (13.5–15.6) | 499 | 11.8 (10.8–12.8) | |||||||
Levofloxacin | 99 | 7.1 (5.7–8.5) | 220 | 6.9 (6.0–7.8) | 289 | 6.6 (5.8–7.3) | 368 | 8.7 (7.8–9.6) | |||||||
Trimethoprim/sulfamethoxazole | 320 | 22.9 (20.6–25.1) | 235 | 7.3 (6.4–8.3) | 280 | 6.4 (5.6–7.1) | 277 | 6.6 (5.8–7.3) | |||||||
Pipemidic acid | 9 | 0.7 (0.2–1.2) | 15 | 0.5 (0.2–0.7) | 213 | 4.8 (4.2–5.5) | 207 | 4.9 (4.2–5.5) | |||||||
Amoxicillin+clavulanic acid | 74 | 5.3 (4.1–6.5) | 101 | 3.2 (2.5–3.8) | 123 | 2.8 (2.3–3.3) | 126 | 3.0 (2.4–3.5) | |||||||
Pefloxacin | 123 | 8.8 (7.3–10.3) | 143 | 4.5 (3.7–5.2) | 159 | 3.6 (3.0–4.2) | 124 | 2.9 (2.4–3.4) | |||||||
Lomefloxacin | 193 | 13.8 (12.0–15.7) | 177 | 5.5 (4.7–6.3) | 132 | 3.0 (2.5–3.5) | 123 | 2.9 (2.4–3.4) | |||||||
Nitrofurantoin | 3 | 0.2 (0.04–0.6) | 3 | 0.1 (0.01–0.2) | 49 | 1.1 (0.8–1.4) | 69 | 1.6 (1.2–2.0) | |||||||
Amoxicillin | 71 | 5.1 (3.9–6.3) | 63 | 2.0 (1.5–2.5) | 58 | 1.3 (1.0–1.6) | 67 | 1.6 (1.2–2.0) | |||||||
Cinoxacin | 8 | 0.6 (0.2–1.1) | 5 | 0.1 (0.05–0.3) | 35 | 0.8 (0.5–1.1) | 46 | 1.1 (0.7–1.4) | |||||||
Others | 267 | 19.1 (17.0–21.2) | 270 | 8.4 (7.4–9.4) | 284 | 6.5 (5.7–7.2) | 251 | 5.9 (5.2–6.7) |
. | Years (no. of acute uncomplicated cystitis cases) . | . | . | . | . | . | . | . | |||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
. | 1999 (n = 1399) . | . | 2000 (n = 3200) . | . | 2001 (n = 4403) . | . | 2002 (n = 4221) . | . | |||||||
Antibiotics . | No. of users . | % (95% CI) . | No. of users . | % (95% CI) . | No. of users . | % (95% CI) . | No. of users . | % (95% CI) . | |||||||
Fosfomycin trometamol | 74 | 5.3 (4.1–6.5) | 81 | 2.5 (2.0–3.1) | 1154 | 26.2 (24.9–27.5) | 1425 | 33.8 (32.3–35.2) | |||||||
Ciprofloxacin | 378 | 27.0 (24.7–29.4) | 422 | 13.2 (12.0–14.4) | 532 | 12.1 (11.1–13.0) | 542 | 12.8 (11.8–13.8) | |||||||
Norfloxacin | 562 | 40.1 (37.2–42.7) | 673 | 21.0 (19.6–22.4) | 640 | 14.5 (13.5–15.6) | 499 | 11.8 (10.8–12.8) | |||||||
Levofloxacin | 99 | 7.1 (5.7–8.5) | 220 | 6.9 (6.0–7.8) | 289 | 6.6 (5.8–7.3) | 368 | 8.7 (7.8–9.6) | |||||||
Trimethoprim/sulfamethoxazole | 320 | 22.9 (20.6–25.1) | 235 | 7.3 (6.4–8.3) | 280 | 6.4 (5.6–7.1) | 277 | 6.6 (5.8–7.3) | |||||||
Pipemidic acid | 9 | 0.7 (0.2–1.2) | 15 | 0.5 (0.2–0.7) | 213 | 4.8 (4.2–5.5) | 207 | 4.9 (4.2–5.5) | |||||||
Amoxicillin+clavulanic acid | 74 | 5.3 (4.1–6.5) | 101 | 3.2 (2.5–3.8) | 123 | 2.8 (2.3–3.3) | 126 | 3.0 (2.4–3.5) | |||||||
Pefloxacin | 123 | 8.8 (7.3–10.3) | 143 | 4.5 (3.7–5.2) | 159 | 3.6 (3.0–4.2) | 124 | 2.9 (2.4–3.4) | |||||||
Lomefloxacin | 193 | 13.8 (12.0–15.7) | 177 | 5.5 (4.7–6.3) | 132 | 3.0 (2.5–3.5) | 123 | 2.9 (2.4–3.4) | |||||||
Nitrofurantoin | 3 | 0.2 (0.04–0.6) | 3 | 0.1 (0.01–0.2) | 49 | 1.1 (0.8–1.4) | 69 | 1.6 (1.2–2.0) | |||||||
Amoxicillin | 71 | 5.1 (3.9–6.3) | 63 | 2.0 (1.5–2.5) | 58 | 1.3 (1.0–1.6) | 67 | 1.6 (1.2–2.0) | |||||||
Cinoxacin | 8 | 0.6 (0.2–1.1) | 5 | 0.1 (0.05–0.3) | 35 | 0.8 (0.5–1.1) | 46 | 1.1 (0.7–1.4) | |||||||
Others | 267 | 19.1 (17.0–21.2) | 270 | 8.4 (7.4–9.4) | 284 | 6.5 (5.7–7.2) | 251 | 5.9 (5.2–6.7) |
Geographic distribution of acute uncomplicated cystitis cases in the year 2002.
. | Years (no. of acute complicated cystitis cases) . | . | . | . | . | . | . | . | |||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
. | 1999 (n = 2235) . | . | 2000 (n = 5077) . | . | 2001 (n = 6644) . | . | 2002 (n = 6547) . | . | |||||||
Antibiotic . | No. of users . | % (95% CI) . | No. of users . | % (95% CI) . | No. of users . | % (95% CI) . | No. of users . | % (95% CI) . | |||||||
Fosfomycin trometamol | 71 | 3.2 (2.4–3.9) | 107 | 2.1 (1.7–2.5) | 1303 | 19.6 (18.6–20.5) | 1517 | 23.2 (22.1–24.2) | |||||||
Ciprofloxacin | 718 | 32.1 (30.1–34.1) | 845 | 16.6 (15.6–17.6) | 1013 | 15.3 (14.3–16.1) | 1118 | 17.1 (16.1–18.0) | |||||||
Norfloxacin | 939 | 42.0 (39.9–44.0) | 1080 | 21.3 (20.1–22.4) | 1026 | 15.4 (14.5–16.3) | 969 | 14.8 (13.9–15.6) | |||||||
Levofloxacin | 193 | 8.7 (7.5–9.8) | 403 | 7.9 (7.2–8.7) | 581 | 8.7 (8.0–9.4) | 709 | 10.8 (10.0–11.6) | |||||||
Trimethoprim/sulfamethoxazole | 425 | 19.0 (17.4–20.7) | 389 | 7.7 (6.9–8.4) | 428 | 6.4 (5.8–7.0) | 473 | 7.2 (6.6–7.8) | |||||||
Pipemidic acid | 13 | 0.6 (0.3–0.9) | 26 | 0.5 (0.3–0.7) | 391 | 5.9 (5.3–6.4) | 390 | 6.0 (5.3–6.5) | |||||||
Lomefloxacin | 320 | 14.3 (12.8–15.8) | 361 | 7.1 (6.4–7.8) | 309 | 4.6 (4.1–5.1) | 295 | 4.5 (4.0–5.0) | |||||||
Pefloxacin | 192 | 8.6 (7.4–9.8) | 227 | 4.5 (3.9–5.0) | 214 | 3.2 (2.8–3.6) | 205 | 3.1 (2.7–3.5) | |||||||
Amoxicillin+clavulanic acid | 113 | 5.0 (4.1–6.0) | 133 | 2.6 (2.1–3.0) | 178 | 2.7 (2.3–3.0) | 184 | 2.8 (2.4–3.2) | |||||||
Cinoxacin | 2 | 0.1 (0.01–0.3) | 8 | 0.2 (0.06–0.3) | 81 | 1.2 (0.9–1.5) | 90 | 1.4 (1.1–1.6) | |||||||
Nitrofurantoin | 11 | 0.5 (0.2–0.8) | 12 | 0.2 (0.1–0.4) | 92 | 1.4 (1.1–1.6) | 90 | 1.4 (1.1–1.6) | |||||||
Others | 541 | 24.2 (22.4–26.0) | 626 | 12.3 (11.4–13.2) | 564 | 8.5 (7.8–9.1) | 543 | 8.3 (7.6–8.9) |
. | Years (no. of acute complicated cystitis cases) . | . | . | . | . | . | . | . | |||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
. | 1999 (n = 2235) . | . | 2000 (n = 5077) . | . | 2001 (n = 6644) . | . | 2002 (n = 6547) . | . | |||||||
Antibiotic . | No. of users . | % (95% CI) . | No. of users . | % (95% CI) . | No. of users . | % (95% CI) . | No. of users . | % (95% CI) . | |||||||
Fosfomycin trometamol | 71 | 3.2 (2.4–3.9) | 107 | 2.1 (1.7–2.5) | 1303 | 19.6 (18.6–20.5) | 1517 | 23.2 (22.1–24.2) | |||||||
Ciprofloxacin | 718 | 32.1 (30.1–34.1) | 845 | 16.6 (15.6–17.6) | 1013 | 15.3 (14.3–16.1) | 1118 | 17.1 (16.1–18.0) | |||||||
Norfloxacin | 939 | 42.0 (39.9–44.0) | 1080 | 21.3 (20.1–22.4) | 1026 | 15.4 (14.5–16.3) | 969 | 14.8 (13.9–15.6) | |||||||
Levofloxacin | 193 | 8.7 (7.5–9.8) | 403 | 7.9 (7.2–8.7) | 581 | 8.7 (8.0–9.4) | 709 | 10.8 (10.0–11.6) | |||||||
Trimethoprim/sulfamethoxazole | 425 | 19.0 (17.4–20.7) | 389 | 7.7 (6.9–8.4) | 428 | 6.4 (5.8–7.0) | 473 | 7.2 (6.6–7.8) | |||||||
Pipemidic acid | 13 | 0.6 (0.3–0.9) | 26 | 0.5 (0.3–0.7) | 391 | 5.9 (5.3–6.4) | 390 | 6.0 (5.3–6.5) | |||||||
Lomefloxacin | 320 | 14.3 (12.8–15.8) | 361 | 7.1 (6.4–7.8) | 309 | 4.6 (4.1–5.1) | 295 | 4.5 (4.0–5.0) | |||||||
Pefloxacin | 192 | 8.6 (7.4–9.8) | 227 | 4.5 (3.9–5.0) | 214 | 3.2 (2.8–3.6) | 205 | 3.1 (2.7–3.5) | |||||||
Amoxicillin+clavulanic acid | 113 | 5.0 (4.1–6.0) | 133 | 2.6 (2.1–3.0) | 178 | 2.7 (2.3–3.0) | 184 | 2.8 (2.4–3.2) | |||||||
Cinoxacin | 2 | 0.1 (0.01–0.3) | 8 | 0.2 (0.06–0.3) | 81 | 1.2 (0.9–1.5) | 90 | 1.4 (1.1–1.6) | |||||||
Nitrofurantoin | 11 | 0.5 (0.2–0.8) | 12 | 0.2 (0.1–0.4) | 92 | 1.4 (1.1–1.6) | 90 | 1.4 (1.1–1.6) | |||||||
Others | 541 | 24.2 (22.4–26.0) | 626 | 12.3 (11.4–13.2) | 564 | 8.5 (7.8–9.1) | 543 | 8.3 (7.6–8.9) |
Geographic distribution of acute complicated cystitis cases in the year 2002.
. | Years (no. of acute complicated cystitis cases) . | . | . | . | . | . | . | . | |||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
. | 1999 (n = 2235) . | . | 2000 (n = 5077) . | . | 2001 (n = 6644) . | . | 2002 (n = 6547) . | . | |||||||
Antibiotic . | No. of users . | % (95% CI) . | No. of users . | % (95% CI) . | No. of users . | % (95% CI) . | No. of users . | % (95% CI) . | |||||||
Fosfomycin trometamol | 71 | 3.2 (2.4–3.9) | 107 | 2.1 (1.7–2.5) | 1303 | 19.6 (18.6–20.5) | 1517 | 23.2 (22.1–24.2) | |||||||
Ciprofloxacin | 718 | 32.1 (30.1–34.1) | 845 | 16.6 (15.6–17.6) | 1013 | 15.3 (14.3–16.1) | 1118 | 17.1 (16.1–18.0) | |||||||
Norfloxacin | 939 | 42.0 (39.9–44.0) | 1080 | 21.3 (20.1–22.4) | 1026 | 15.4 (14.5–16.3) | 969 | 14.8 (13.9–15.6) | |||||||
Levofloxacin | 193 | 8.7 (7.5–9.8) | 403 | 7.9 (7.2–8.7) | 581 | 8.7 (8.0–9.4) | 709 | 10.8 (10.0–11.6) | |||||||
Trimethoprim/sulfamethoxazole | 425 | 19.0 (17.4–20.7) | 389 | 7.7 (6.9–8.4) | 428 | 6.4 (5.8–7.0) | 473 | 7.2 (6.6–7.8) | |||||||
Pipemidic acid | 13 | 0.6 (0.3–0.9) | 26 | 0.5 (0.3–0.7) | 391 | 5.9 (5.3–6.4) | 390 | 6.0 (5.3–6.5) | |||||||
Lomefloxacin | 320 | 14.3 (12.8–15.8) | 361 | 7.1 (6.4–7.8) | 309 | 4.6 (4.1–5.1) | 295 | 4.5 (4.0–5.0) | |||||||
Pefloxacin | 192 | 8.6 (7.4–9.8) | 227 | 4.5 (3.9–5.0) | 214 | 3.2 (2.8–3.6) | 205 | 3.1 (2.7–3.5) | |||||||
Amoxicillin+clavulanic acid | 113 | 5.0 (4.1–6.0) | 133 | 2.6 (2.1–3.0) | 178 | 2.7 (2.3–3.0) | 184 | 2.8 (2.4–3.2) | |||||||
Cinoxacin | 2 | 0.1 (0.01–0.3) | 8 | 0.2 (0.06–0.3) | 81 | 1.2 (0.9–1.5) | 90 | 1.4 (1.1–1.6) | |||||||
Nitrofurantoin | 11 | 0.5 (0.2–0.8) | 12 | 0.2 (0.1–0.4) | 92 | 1.4 (1.1–1.6) | 90 | 1.4 (1.1–1.6) | |||||||
Others | 541 | 24.2 (22.4–26.0) | 626 | 12.3 (11.4–13.2) | 564 | 8.5 (7.8–9.1) | 543 | 8.3 (7.6–8.9) |
. | Years (no. of acute complicated cystitis cases) . | . | . | . | . | . | . | . | |||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
. | 1999 (n = 2235) . | . | 2000 (n = 5077) . | . | 2001 (n = 6644) . | . | 2002 (n = 6547) . | . | |||||||
Antibiotic . | No. of users . | % (95% CI) . | No. of users . | % (95% CI) . | No. of users . | % (95% CI) . | No. of users . | % (95% CI) . | |||||||
Fosfomycin trometamol | 71 | 3.2 (2.4–3.9) | 107 | 2.1 (1.7–2.5) | 1303 | 19.6 (18.6–20.5) | 1517 | 23.2 (22.1–24.2) | |||||||
Ciprofloxacin | 718 | 32.1 (30.1–34.1) | 845 | 16.6 (15.6–17.6) | 1013 | 15.3 (14.3–16.1) | 1118 | 17.1 (16.1–18.0) | |||||||
Norfloxacin | 939 | 42.0 (39.9–44.0) | 1080 | 21.3 (20.1–22.4) | 1026 | 15.4 (14.5–16.3) | 969 | 14.8 (13.9–15.6) | |||||||
Levofloxacin | 193 | 8.7 (7.5–9.8) | 403 | 7.9 (7.2–8.7) | 581 | 8.7 (8.0–9.4) | 709 | 10.8 (10.0–11.6) | |||||||
Trimethoprim/sulfamethoxazole | 425 | 19.0 (17.4–20.7) | 389 | 7.7 (6.9–8.4) | 428 | 6.4 (5.8–7.0) | 473 | 7.2 (6.6–7.8) | |||||||
Pipemidic acid | 13 | 0.6 (0.3–0.9) | 26 | 0.5 (0.3–0.7) | 391 | 5.9 (5.3–6.4) | 390 | 6.0 (5.3–6.5) | |||||||
Lomefloxacin | 320 | 14.3 (12.8–15.8) | 361 | 7.1 (6.4–7.8) | 309 | 4.6 (4.1–5.1) | 295 | 4.5 (4.0–5.0) | |||||||
Pefloxacin | 192 | 8.6 (7.4–9.8) | 227 | 4.5 (3.9–5.0) | 214 | 3.2 (2.8–3.6) | 205 | 3.1 (2.7–3.5) | |||||||
Amoxicillin+clavulanic acid | 113 | 5.0 (4.1–6.0) | 133 | 2.6 (2.1–3.0) | 178 | 2.7 (2.3–3.0) | 184 | 2.8 (2.4–3.2) | |||||||
Cinoxacin | 2 | 0.1 (0.01–0.3) | 8 | 0.2 (0.06–0.3) | 81 | 1.2 (0.9–1.5) | 90 | 1.4 (1.1–1.6) | |||||||
Nitrofurantoin | 11 | 0.5 (0.2–0.8) | 12 | 0.2 (0.1–0.4) | 92 | 1.4 (1.1–1.6) | 90 | 1.4 (1.1–1.6) | |||||||
Others | 541 | 24.2 (22.4–26.0) | 626 | 12.3 (11.4–13.2) | 564 | 8.5 (7.8–9.1) | 543 | 8.3 (7.6–8.9) |
Geographic distribution of acute complicated cystitis cases in the year 2002.
. | Years (no. of recurrent cystitis cases) . | . | . | . | . | . | . | . | |||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
. | 1999 (n = 269) . | . | 2000 (n = 504) . | . | 2001 (n = 365) . | . | 2002 (n = 265) . | . | |||||||
Antibiotic . | No. of users . | % (95% CI) . | No. of users . | % (95% CI) . | No. of users . | % (95% CI) . | No. of users . | % (95% CI) . | |||||||
Fosfomycin trometamol | 2 | 0.6 (0.09–2.6) | 7 | 1.4 (0.4–2.8) | 74 | 20.4 (16.2–24.7) | 84 | 31.7 (26.1–37.6) | |||||||
Ciprofloxacin | 32 | 11.7 (8.2–16.3) | 38 | 7.6 (5.3–10.2) | 62 | 17.0 (13.2–21.2) | 53 | 20.0 (15.3–25.3) | |||||||
Norfloxacin | 25 | 9.3 (6.1–13.4) | 38 | 7.5 (5.3–10.2) | 43 | 11.9 (8.6–15.5) | 40 | 15.1 (11.0–19.9) | |||||||
Pipemidic acid | – | – | – | – | 12 | 3.2 (1.7–5.6) | 16 | 6.0 (3.4–9.6) | |||||||
Levofloxacin | 7 | 2.5 (1.0–5.2) | 18 | 3.5 (2.1–5.5) | 19 | 5.1 (3.1–8.0) | 16 | 6.0 (3.4–9.6) | |||||||
Trimethoprim/sulfamethoxazole | 8 | 3.1 (1.2–5.7) | 7 | 1.5 (0.5–2.8) | 11 | 3.0 (1.5–5.3) | 14 | 5.3 (2.9–8.7) | |||||||
Amoxicillin+clavulanic acid | 10 | 3.8 (1.7–6.7) | 17 | 3.4 (1.9–5.3) | 13 | 3.4 (1.9–6.0) | 10 | 3.8 (1.8–6.8) | |||||||
Cinoxacin | – | – | 1 | 0.2 (0.05–1.1) | 3 | 0.9 (0.1–2.3) | 8 | 3.0 (1.3–5.8) | |||||||
Lomefloxacin | 11 | 4.3 (2.0–7.1) | 18 | 3.5 (2.1–5.5) | 12 | 3.3 (1.7–5.6) | 6 | 2.3 (0.8–4.8) | |||||||
Pefloxacin | 19 | 7.0 (4.3–10.8) | 13 | 2.5 (1.3–4.3) | 11 | 3.0 (1.5–5.3) | 5 | 1.9 (0.6–4.3) | |||||||
Ofloxacin | 2 | 0.7 (0.09–2.6) | 2 | 0.5 (0.04–1.0) | 1 | 0.2 (0.06–1.0) | 4 | 1.5 (0.4–3.8) | |||||||
Nitrofurantoin | 1 | 0.4 (0.09–2.0) | 1 | 0.2 (0.05–1.1) | 4 | 1.1 (0.2–2.7) | 3 | 1.1 (0.2–3.2) | |||||||
Others | 37 | 13.9 (9.8–18.4) | 29 | 5.8 (3.8–8.1) | 33 | 9.1 (6.3–12.4) | 20 | 7.5 (4.6–11.4) |
. | Years (no. of recurrent cystitis cases) . | . | . | . | . | . | . | . | |||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
. | 1999 (n = 269) . | . | 2000 (n = 504) . | . | 2001 (n = 365) . | . | 2002 (n = 265) . | . | |||||||
Antibiotic . | No. of users . | % (95% CI) . | No. of users . | % (95% CI) . | No. of users . | % (95% CI) . | No. of users . | % (95% CI) . | |||||||
Fosfomycin trometamol | 2 | 0.6 (0.09–2.6) | 7 | 1.4 (0.4–2.8) | 74 | 20.4 (16.2–24.7) | 84 | 31.7 (26.1–37.6) | |||||||
Ciprofloxacin | 32 | 11.7 (8.2–16.3) | 38 | 7.6 (5.3–10.2) | 62 | 17.0 (13.2–21.2) | 53 | 20.0 (15.3–25.3) | |||||||
Norfloxacin | 25 | 9.3 (6.1–13.4) | 38 | 7.5 (5.3–10.2) | 43 | 11.9 (8.6–15.5) | 40 | 15.1 (11.0–19.9) | |||||||
Pipemidic acid | – | – | – | – | 12 | 3.2 (1.7–5.6) | 16 | 6.0 (3.4–9.6) | |||||||
Levofloxacin | 7 | 2.5 (1.0–5.2) | 18 | 3.5 (2.1–5.5) | 19 | 5.1 (3.1–8.0) | 16 | 6.0 (3.4–9.6) | |||||||
Trimethoprim/sulfamethoxazole | 8 | 3.1 (1.2–5.7) | 7 | 1.5 (0.5–2.8) | 11 | 3.0 (1.5–5.3) | 14 | 5.3 (2.9–8.7) | |||||||
Amoxicillin+clavulanic acid | 10 | 3.8 (1.7–6.7) | 17 | 3.4 (1.9–5.3) | 13 | 3.4 (1.9–6.0) | 10 | 3.8 (1.8–6.8) | |||||||
Cinoxacin | – | – | 1 | 0.2 (0.05–1.1) | 3 | 0.9 (0.1–2.3) | 8 | 3.0 (1.3–5.8) | |||||||
Lomefloxacin | 11 | 4.3 (2.0–7.1) | 18 | 3.5 (2.1–5.5) | 12 | 3.3 (1.7–5.6) | 6 | 2.3 (0.8–4.8) | |||||||
Pefloxacin | 19 | 7.0 (4.3–10.8) | 13 | 2.5 (1.3–4.3) | 11 | 3.0 (1.5–5.3) | 5 | 1.9 (0.6–4.3) | |||||||
Ofloxacin | 2 | 0.7 (0.09–2.6) | 2 | 0.5 (0.04–1.0) | 1 | 0.2 (0.06–1.0) | 4 | 1.5 (0.4–3.8) | |||||||
Nitrofurantoin | 1 | 0.4 (0.09–2.0) | 1 | 0.2 (0.05–1.1) | 4 | 1.1 (0.2–2.7) | 3 | 1.1 (0.2–3.2) | |||||||
Others | 37 | 13.9 (9.8–18.4) | 29 | 5.8 (3.8–8.1) | 33 | 9.1 (6.3–12.4) | 20 | 7.5 (4.6–11.4) |
Geographic distribution of recurrent cystitis cases in the year 2002.
. | Years (no. of recurrent cystitis cases) . | . | . | . | . | . | . | . | |||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
. | 1999 (n = 269) . | . | 2000 (n = 504) . | . | 2001 (n = 365) . | . | 2002 (n = 265) . | . | |||||||
Antibiotic . | No. of users . | % (95% CI) . | No. of users . | % (95% CI) . | No. of users . | % (95% CI) . | No. of users . | % (95% CI) . | |||||||
Fosfomycin trometamol | 2 | 0.6 (0.09–2.6) | 7 | 1.4 (0.4–2.8) | 74 | 20.4 (16.2–24.7) | 84 | 31.7 (26.1–37.6) | |||||||
Ciprofloxacin | 32 | 11.7 (8.2–16.3) | 38 | 7.6 (5.3–10.2) | 62 | 17.0 (13.2–21.2) | 53 | 20.0 (15.3–25.3) | |||||||
Norfloxacin | 25 | 9.3 (6.1–13.4) | 38 | 7.5 (5.3–10.2) | 43 | 11.9 (8.6–15.5) | 40 | 15.1 (11.0–19.9) | |||||||
Pipemidic acid | – | – | – | – | 12 | 3.2 (1.7–5.6) | 16 | 6.0 (3.4–9.6) | |||||||
Levofloxacin | 7 | 2.5 (1.0–5.2) | 18 | 3.5 (2.1–5.5) | 19 | 5.1 (3.1–8.0) | 16 | 6.0 (3.4–9.6) | |||||||
Trimethoprim/sulfamethoxazole | 8 | 3.1 (1.2–5.7) | 7 | 1.5 (0.5–2.8) | 11 | 3.0 (1.5–5.3) | 14 | 5.3 (2.9–8.7) | |||||||
Amoxicillin+clavulanic acid | 10 | 3.8 (1.7–6.7) | 17 | 3.4 (1.9–5.3) | 13 | 3.4 (1.9–6.0) | 10 | 3.8 (1.8–6.8) | |||||||
Cinoxacin | – | – | 1 | 0.2 (0.05–1.1) | 3 | 0.9 (0.1–2.3) | 8 | 3.0 (1.3–5.8) | |||||||
Lomefloxacin | 11 | 4.3 (2.0–7.1) | 18 | 3.5 (2.1–5.5) | 12 | 3.3 (1.7–5.6) | 6 | 2.3 (0.8–4.8) | |||||||
Pefloxacin | 19 | 7.0 (4.3–10.8) | 13 | 2.5 (1.3–4.3) | 11 | 3.0 (1.5–5.3) | 5 | 1.9 (0.6–4.3) | |||||||
Ofloxacin | 2 | 0.7 (0.09–2.6) | 2 | 0.5 (0.04–1.0) | 1 | 0.2 (0.06–1.0) | 4 | 1.5 (0.4–3.8) | |||||||
Nitrofurantoin | 1 | 0.4 (0.09–2.0) | 1 | 0.2 (0.05–1.1) | 4 | 1.1 (0.2–2.7) | 3 | 1.1 (0.2–3.2) | |||||||
Others | 37 | 13.9 (9.8–18.4) | 29 | 5.8 (3.8–8.1) | 33 | 9.1 (6.3–12.4) | 20 | 7.5 (4.6–11.4) |
. | Years (no. of recurrent cystitis cases) . | . | . | . | . | . | . | . | |||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
. | 1999 (n = 269) . | . | 2000 (n = 504) . | . | 2001 (n = 365) . | . | 2002 (n = 265) . | . | |||||||
Antibiotic . | No. of users . | % (95% CI) . | No. of users . | % (95% CI) . | No. of users . | % (95% CI) . | No. of users . | % (95% CI) . | |||||||
Fosfomycin trometamol | 2 | 0.6 (0.09–2.6) | 7 | 1.4 (0.4–2.8) | 74 | 20.4 (16.2–24.7) | 84 | 31.7 (26.1–37.6) | |||||||
Ciprofloxacin | 32 | 11.7 (8.2–16.3) | 38 | 7.6 (5.3–10.2) | 62 | 17.0 (13.2–21.2) | 53 | 20.0 (15.3–25.3) | |||||||
Norfloxacin | 25 | 9.3 (6.1–13.4) | 38 | 7.5 (5.3–10.2) | 43 | 11.9 (8.6–15.5) | 40 | 15.1 (11.0–19.9) | |||||||
Pipemidic acid | – | – | – | – | 12 | 3.2 (1.7–5.6) | 16 | 6.0 (3.4–9.6) | |||||||
Levofloxacin | 7 | 2.5 (1.0–5.2) | 18 | 3.5 (2.1–5.5) | 19 | 5.1 (3.1–8.0) | 16 | 6.0 (3.4–9.6) | |||||||
Trimethoprim/sulfamethoxazole | 8 | 3.1 (1.2–5.7) | 7 | 1.5 (0.5–2.8) | 11 | 3.0 (1.5–5.3) | 14 | 5.3 (2.9–8.7) | |||||||
Amoxicillin+clavulanic acid | 10 | 3.8 (1.7–6.7) | 17 | 3.4 (1.9–5.3) | 13 | 3.4 (1.9–6.0) | 10 | 3.8 (1.8–6.8) | |||||||
Cinoxacin | – | – | 1 | 0.2 (0.05–1.1) | 3 | 0.9 (0.1–2.3) | 8 | 3.0 (1.3–5.8) | |||||||
Lomefloxacin | 11 | 4.3 (2.0–7.1) | 18 | 3.5 (2.1–5.5) | 12 | 3.3 (1.7–5.6) | 6 | 2.3 (0.8–4.8) | |||||||
Pefloxacin | 19 | 7.0 (4.3–10.8) | 13 | 2.5 (1.3–4.3) | 11 | 3.0 (1.5–5.3) | 5 | 1.9 (0.6–4.3) | |||||||
Ofloxacin | 2 | 0.7 (0.09–2.6) | 2 | 0.5 (0.04–1.0) | 1 | 0.2 (0.06–1.0) | 4 | 1.5 (0.4–3.8) | |||||||
Nitrofurantoin | 1 | 0.4 (0.09–2.0) | 1 | 0.2 (0.05–1.1) | 4 | 1.1 (0.2–2.7) | 3 | 1.1 (0.2–3.2) | |||||||
Others | 37 | 13.9 (9.8–18.4) | 29 | 5.8 (3.8–8.1) | 33 | 9.1 (6.3–12.4) | 20 | 7.5 (4.6–11.4) |
Geographic distribution of recurrent cystitis cases in the year 2002.
Conversely, fosfomycin trometamol increased dramatically and became the first choice for any type of cystitis in the year 2002. More than 50% of fosfomycin users were recorded during the year 2002 and >80% were females. Only in acute uncomplicated cystitis, owing to its own definition, they mostly involved younger patients (85.8%), whereas for acute complicated and recurrent cystitis fosfomycin trometanol users were more likely to be older patients.
Discussion
This study describes the prescribing behaviour of Italian GPs in managing acute and recurrent cystitis and shows a significant increase in antibiotic treatment during a 4 year period. Since patient demographics did not vary in the study period, changes in practice behaviour should fully explain the different trends in antibiotic use during the years.
In assessing patient features, except for the complicated type, women resulted in >80% of cases, similar to the results from a previous Italian study developed in a GP setting.5 The percentage of urine culture tests recorded was lower for acute and recurrent cystitis. Although a possible under-reporting of diagnostic test has been taken into account, the results for uncomplicated cystitis are consistently reported from literature, because in women with acute uncomplicated cystitis, empirical therapy without a pretherapy urine culture is often used.2,9 On the contrary, the low percentage of urine culture analysis related to recurrent cystitis is not in line with the current indications because recurrent type should be documented by culture at least once.7 Antibiotic use was found to be associated with the increased severity of the health status. This might be explained by the presence of more severe co-morbidity leading GPs to be more aware of the patients and consequently to treat them with antibiotics.
The results also show an increase in the prescribing rates during the 4 year period. This is mainly related to the use of fosfomycin trometamol, and it is confirmed by the Italian Department of Health where during the year 2001 a 35.9% increase in use was reported, compared with 2000.17 The main explanation for such rapid increase might be related to the use of fosfomycin in a single-dose, and to the good tolerability profile, which led GPs to use such medication without any laboratory test for bacterial confirmation. However, in uncomplicated cystitis where the highest prevalence of users was found, fosfomycin trometamol use is proposed as an option to trimethoprim/sulfamethoxazole although its use as single-dose therapy needs further trials to demonstrate its effectiveness.18,19 On the other hand, several scientific studies confirmed its effectiveness against pathogens in urinary tract infections, thus suggesting that fosfomycin trometamol may be a useful alternative as single-dose therapy of uncomplicated UTIs.20 Those data were recently confirmed because fosfomycin trometamol has maintained throughout the years its activity and has shown stable rates of resistance, thus, remaining a drug of choice for the eradication of uncomplicated UTI.2,21,22
Among women with risk factors for infection with resistant bacteria, or in the setting of a high prevalence of trimethoprim/sulfamethoxazole resistance, fluoroquinolones should be considered for empirical treatment, being an alternative therapy.4,23 Particularly in Italy, current prevalence of antibiotic susceptibility in 387 E. coli isolated from uncomplicated UTIs resulted in 76% for co-trimoxazole.22 Therefore, because of growing rates of resistance, fluoroquinolones have taken on an expanding management role for UTIs, confirming their high use observed in our survey.24
Our results on antibiotic prescription in acute uncomplicated cystitis confirm this evidence and the high use of fosfomycin observed is strengthened by several sources. Conversely, with regard to complicated cystitis, being a large amount of our acute cases, the European Association of Urology (EAU) guidelines address treatment recommending the use of a fluoroquinolone, a beta-lactam or an aminoglycoside for empiric therapy.1 The prevalence rate of recurrent cystitis in our study was very low, probably owing to the management of this disease by specialists, although its treatment was very similar to acute cystitis. In fact, in recurrent cystitis one effective approach is to prevent infection by using antibiotic prophylaxis (either continuous or post-coital) with trimethoprim/sulfamethoxazole, trimethoprim, nitrofurantoin or a quinolone.4,8,25,26
In conclusion, our data indicate considerable changes in treating acute and recurrent cystitis in Italy during a 4 year period, with an evident rise in antibiotic use for acute cystitis mostly related to fosfomycin trometamol. They also indicate that the prescriptive trend from Italian GPs for acute uncomplicated cystitis finds confirmation in available evidence, whereas the management of recurrent cystitis could be further improved. Our results contribute to outline the pattern of antibiotic prescribing of Italian GPs and the patient-related variables associated with antibiotic prescription for cystitis, a disease mainly managed in the general practice setting.
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There are no conflicts of interest.
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Author notes
1Department of Clinical and Experimental Medicine and Pharmacology, University of Messina, Torre Biologica-Policlinico Universitario, Via Consolare Valeria-Gazzi, 98125 Messina, Italy; 2Italian College of General Practitioners, Florence, Italy; 3Health Search, Italian College of General Practitioners, Florence, Italy; 4Microbiology Section, Di.S.C.A.T. Department, University of Genoa, Genoa, Italy; 5Institute of Microbiology, School of Medicine, University of Catania, Catania, Italy