Antibiotic resistance and antibiotic consumption in a region - using the example of community-acquired urinary tract infections

Background In sight of increasing bacterial resistances, appropriate and cautious antibiotic therapy (antibiotic stewardship) is becoming more and more important, in private practices as well. A current S3 guideline is available for the treatment of uncomplicated urinary tract infections, which recommends that regular epidemiological examinations of pathogen sensitivity are to be carried out promptly and locally. With this said, the antibiotic prescriptions of the resident doctors in Hesse were examined and compared with the sensitivity of the most important pathogens causing urinary tract infections. Material and method The prescription data for antibiotics (ATC J01) for the area of the Association of Statutory Health Insurance Physicians in Hessen for the years 2013 to 2020 were received from Insight Health GmbH & Co. KG, Waldems-Esch, which manages the data. A large laboratory that supplies numerous resident doctors in the Rhine-Main region provided sensitivity data tested according to CLSI until the year 2016 and from 2017 to EUCAST from microbiological examinations of urine samples for the clarification of community-acquired urinary tract infections from the years 2011-2020. Results From 2013 to 2020 the antibiotic prescriptions decreased from 2 692 370 to 1 708 134 (minus 37 %). The prescriptions for cephalosporins were reduced by more than 40 %, those of quinolones by 76%. Among the antibiotics recommended for urinary tract infections, the most common antibiotics used were fosfomycin (2020: 130 476), followed by co-trimoxazole (2020: 96 559), nitrofurantoin (2020: 37 415), trimethoprim (2020: 27 388), pivmecillinam (20 984) and nitroxoline (6818). Urologists, on the other hand, most frequently prescribed nitrofurantoin (2020: 9951) and co-trimoxazole (9772), followed by fosfomycin (7193), trimethoprim (5050), nitroxoline (3289) and pivmecillinam (2722). Despite the high use of fosfomycin in outpatient medicine, E. coli and Citrobacter spp. exhibited no loss of sensitivity, Proteus mirabilis and S. aureus showed a slight loss of activity, while in Enterobacter cloacae a clear loss of activity was seen. The E. coli strains detected from urine samples to clarify complicated urinary tract infections show continuously excellent sensitivity for fosfomycin, nitrofurantoin, nitroxoline and mecillinam (> > 90%), whereas the sensitivity against trimethoprim was just under 80 %. Discussion and conclusion The decrease in antibiotic prescription data from statutory health insurance physicians in Hesse shows that the importance of cautious antibiotic therapy is also gaining ground in outpatient practice. Co-trimoxazole, which continues to be used very frequently, should be avoided in favor of monotherapy with trimethoprim because of the increased side effects of the sulfonamide component with the same effectiveness of trimethoprim. The E. coli strains detected from urine samples to clarify complicated urinary tract infections showed a sensitivity, of just under 80% to trimethoprim. Since an approximately 10% better sensitivity rate was found for uncomplicated community-acquired urinary tract infections that usually do not require microbiological diagnostics, in our opinion, in transferring this observation in the Rhine-Main area and in Hesse, trimethoprim can also continue to be used empirically for uncomplicated urinary tract infections.