Fluoroquinolone should be reconsidered as empirical therapy for adult inpatient urinary tract infections in tertiary hospital: a perspective descriptive study from the microbiological and cost-effectiveness aspects

Main Article Content

I Ketut Agus Indra Adhiputra
Marta Setiabudy


fluoroquinolone, empirical therapy, urinary tract infection


Background: Urinary Tract Infections (UTI) has become difficult to treat because of its increasing resistance characteristics to antimicrobial agents, especially to fluoroquinolone. The objective of this study was to describe the effectiveness of fluoroquinolone as empirical therapy for adult inpatient UTI.

Methods: This descriptive cross-sectional study was performed at Prof. Dr. I.G.N.G. Ngoerah Hospital, a tertiary Hospital in Denpasar, Bali, from January 2020 until March 2020. All urine specimens were examined using bioMérieux VITEK® 2 System.

Result: A total of 155 urine samples met the inclusion and exclusion criteria. We found Escherichia coli (39.4%) as the most common microbes followed by Klebsiella pneumoniae (12.3%). Most of the isolates are multi drug resistant organisms (MDRO) (52.9%) and 57% (49) of the Enterobacteriaceae isolates are extended spectrum beta lactamases (ESBLs). The average duration of the empirical antibiotic therapy was 3.7 days for all fluoroquinolone. Ciprofloxacin (53.5%) is the most common empirical therapy, followed by levofloxacin (16.8%). Antimicrobial sensitivity tests showed that bacteria remained highly sensitive to amikacin (96%) and meropenem (94%). The sensitivity test for ciprofloxacin and levofloxacin was only 26% and 4% respectively. The suitability antibiotic results of fluoroquinolone as empirical therapy were only 20% from 110 isolates. The cost ineffectiveness of fluoroquinolone as empirical therapy is Rp.8,402,400 for 3 months.

Conclusion: We concluded that both fluoroquinolone (ciprofloxacin and levofloxacin) have a very low sensitivity rate and are not cost-effective, therefore the use of those antimicrobial agents as empirical therapy should be reconsidered.

Abstract 397 | pdf Downloads 162


1. Wang R, Hacker MR, Lefevre R. Cost-effectiveness of prophylactic antibiotic use to prevent catheter-associated urinary tract infections. Int Urogynecol J. 2020;31(2):285-289.
2. Wagenlehner FME, Bjerklund Johansen TE, Cai T, et al. Epidemiology, definition and treatment of complicated urinary tract infections. Nat Rev Urol. 2020;17(10):586-600.
3. Neugent ML, Hulyalkar NV, Nguyen VH, Zimmern PE, De Nisco NJ. Advances in Understanding the Human Urinary Microbiome and Its Potential Role in Urinary Tract Infection. mBio. 2020;11(2):e00218-20.
4. Waller TA, Pantin SAL, Yenior AL, Pujalte GGA. Urinary Tract Infection Antibiotic Resistance in the United States. Prim Care. 2018;45(3):455-466.
5. Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis. 2010;50(5):625-663.
6. Wang R, LaSala C. Role of antibiotic resistance in urinary tract infection management: a cost-effectiveness analysis. Am J Obstet Gynecol. 2021;225(5):550.e1-550.e10.
7. Mitchell BG, Fasugba O, Gardner A, et al. Reducing catheter-associated urinary tract infections in hospitals: study protocol for a multi-site randomised controlled study. BMJ Open. 2017;7(11):e018871.
8. Foxman B. Epidemiology of urinary tract infections: incidence, morbidity, and economic costs. Dis Mon. 2003;49(2):53-70.
9. Agus Indra Adhiputra IK, Setiabudy M, Sukrama IDM, Budayanti NNS. “Karakteristik sensitivitas dan resistansi antibiotik pada kasus infeksi saluran kemih Escherichia coli di rumah sakit tersier di Bali pada Januari 2019 hingga Desember 2019. “Characteristics of antibiotic sensitivity and resistance in cases of urinary tract infection Escherichia coli at tertiary hospitals in Bali from January 2019 to December 2019. Medicina (B Aires). 2021;52(3):103–7.
10. Luu T, Albarillo FS. Asymptomatic Bacteriuria: Prevalence, Diagnosis, Management, and Current Antimicrobial Stewardship Implementations. Am J Med. 2022;135(8):e236-e244.
11. Whiting P, Westwood M, Bojke L, et al. Clinical effectiveness and cost-effectiveness of tests for the diagnosis and investigation of urinary tract infection in children: a systematic review and economic model. Health Technol Assess. 2006;10(36):iii-154
12. Mitchell BG, Fasugba O, Cheng AC, et al. Chlorhexidine versus saline in reducing the risk of catheter associated urinary tract infection: A cost-effectiveness analysis. Int J Nurs Stud. 2019;97:1-6.
13. Shafrin J, Marijam A, Joshi AV, et al. Impact of suboptimal or inappropriate treatment on healthcare resource use and cost among patients with uncomplicated urinary tract infection: an analysis of integrated delivery network electronic health records. Antimicrob Resist Infect Control. 2022;11(1):133.
14. Sanyal C, Husereau DR, Beahm NP, Smyth D, Tsuyuki RT. Cost-effectiveness and budget impact of the management of uncomplicated urinary tract infection by community pharmacists. BMC Health Serv Res. 2019;19(1):499.
15. Mortazavi-Tabatabaei SAR, Ghaderkhani J, Nazari A, Sayehmiri K, Sayehmiri F, Pakzad I. Pattern of Antibacterial Resistance in Urinary Tract Infections: A Systematic Review and Meta-analysis. Int J Prev Med. 2019;10:169.
16. Patton JP, Nash DB, Abrutyn E. Urinary tract infection: economic considerations. Med Clin North Am. 1991;75(2):495-513.
17. Platt R, Polk BF, Murdock B, Rosner B. Prevention of catheter-associated urinary tract infection: a cost-benefit analysis. Infect Control Hosp Epidemiol. 1989;10(2):60-64.
18. Marschall J, Carpenter CR, Fowler S, Trautner BW; CDC Prevention Epicenters Program. Antibiotic prophylaxis for urinary tract infections after removal of urinary catheter: meta-analysis. BMJ. 2013;346:f3147.
19. Teramae M, Osawa K, Shigemura K, Kitagawa K, Shirakawa T, Fujisawa M, et al. Prevalence of quinolone resistance of extended-spectrum β-lactamase-producing escherichia coli with st131-fimh30 in a city hospital in Hyogo, Japan. Int J Mol Sci. 2019;20(20):1–8.
20. Alanazi MQ. Clinical Efficacy and Cost Analysis of Antibiotics for Treatment of Uncomplicated Urinary Tract Infections in the Emergency Department of a Tertiary Hospital in Saudi Arabia. Ther Clin Risk Manag. 2021;17:1209–17.
21. Sukrama IDM, Pinatih KJP, Hendrayana MA, Rasyid B, Wedari NLPH. Escherichia coli Clonal Variability Based on Genetic Diversity Pattern with Enterobacterial Repetitive Intergenic Consensus-Polymerase Chain Reaction Methods for Traveler’s Diarrhea Cases in Bali. Open Access Maced J Med Sci. 2022;10(A):752-60.
22. Hayati Z, Jamil KF, Azhari A, Mahdani W, Karmil TF, Yossadania A, Dahril, Habibie YA. 2021. Outcome of urinary tract infection caused by Extended Spectrum Beta-Lactamase (ESBL) producingEscherichia coli andKlebsiella pneumoniaein Dr Zainoel Abidin General Hospital Aceh. Bali Medical Journal. 2021;10(2): 544-548.