THE ASSOCIATION BETWEEN PRIOR ANTIBIOTIC EXPOSURE AND ANTIBIOTIC RESISTANT URINARY TRACT INFECTION IN PRIMARY HEALTH CARE CLIENTS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Abstract

This systematic review and meta-analysis aimed to quantify the association between prior antibiotic exposure and subsequent antibiotic resistant urinary tract infection (UTI) in clients in primary healthcare settings. Additionally, it aimed to evaluate the relationships between the timeframe, type of antibiotic, number of courses, dose, and duration of antibiotic exposure, and the likelihood of subsequent antibiotic resistant UTI. A database search of PubMed, Embase, ProQuest and, Scopus was performed to identify relevant articles. Random-effects meta-analysis was conducted to provide pooled estimates of the associations. The data search yielded 1196 articles. Screening of titles and abstracts followed by full text screening yielded 27 relevant articles reporting 77 measurements of association between prior antibiotic exposure and subsequent resistant UTI in primary healthcare clients. Compared to those with no antibiotic treatment for UTI, participants with antibiotic exposure in the previous 12 months of UTI onset were more than twice as likely to have a subsequent antibiotic resistant UTI (pooled odds ratio = 2.289 [95% CI; 2.006-2.612]). Subgroup analysis indicated that participants with antibiotic exposure within the previous 1 month were more than 4 times more likely to have a subsequent antibiotic resistance UTI compared to those with no antibiotic exposure. Resistance to quinolones was the most likely, and participants exposed to quinolones had over five times the odds of subsequent resistance to quinolones. The likelihood of resistance was higher when a patient was exposed to 3 or more antibiotic courses in the previous 12 months compared to 2 or 1 antibiotic course. The OR of the association between resistance and consumption of >=3 antibiotic courses in the last 12 months was 3.315 [95%CI; 3.32-8.12], followed by 2.34 [95%CI; 1.38-4.16] for the consumption of two antibiotic courses, and 1.58 [95%CI; 1.22-2.04] for the consumption of a single antibiotic course. The OR of resistance was non-significant in one study that compared a high dose to lower dose of ?-lactams, OR = 1.00 [95%CI; 0.99-1.01], P-value=0.62. However, in the second included study, a lower dose of amoxicillin was associated with higher odds of ampicillin resistance compared to a higher dose, OR=2.19 [95%CI; 1.08-4.41]. The effect of a longer duration of prior AB course on the likelihood of resistance is greater than the effect of a shorter courses. Based on the results of the single included study evaluating this association, the OR comparing the effect of a longer course to a shorter course of trimethoprim on ampicillin resistance was 2.89 [95%CI; 1.44 to 5.78], and the OR comparing the effect a long course to a short course of amoxicillin on ampicillin resistance was 1.50 [95%CI; 0.76 to 2.92]. Results of this study can support clinicians' decisions upon AB prescribing for UTI in primary care clients when resistance is of concern.