Urinary tract infections (UTI) are a worldwide health problem [1]. Foxman et al. reported that more than 1 million patients were treated for UTIs in emergency departments (ED) in the United States in 2002, costing the healthcare system $3.5 billion annually [2,3]. Treatment decisions in the ED are challenging due to a lack of longitudinal patient health records, potential financial barriers, and a lack of available culture and susceptibility data at the time of antibiotic prescribing. Rates of antimicrobial resistance for the treatment of community-acquired UTIs are increasing [[4], [5], [6]]. Multiple authors have reported antimicrobial susceptibility in various patient populations. Faine et al. reported susceptibility to commonly prescribed antibiotics, specifically citing an increase in fluoroquinolone resistance at 15 emergency department (ED) sites in the US in 2020 [7]. Fleming et al. reported antimicrobial sensitivities to multiple antimicrobial therapies in patients with CA-UTI treated at a community hospital ED [8].

Empiric antibiotic selection for treatment of UTI is based on the prescriber's classification of UTI using the Infectious Diseases Society of America (IDSA) guidelines [[9], [10], [11]]. IDSA disease categories include uncomplicated cystitis or pyelonephritis, as well as catheter-associated urinary tract infections. The IDSA recently released updated recommendations for care of patients with complicated UTI. In addition to the established IDSA categorization, patients can be further classified based on healthcare exposure and risk factors for more drug resistant pathogens as community-acquired urinary tract infections (CA-UTIs) or healthcare-associated urinary tract infections (HA-UTIs) [12]. Across all classification types, Escherichia coli (E. coli) is the most common bacterial pathogen regardless of the subtype treated [13]. In community-acquired urinary tract infections, E. coli typically accounts for 75 to 90 % of cases [14].

Empiric therapy focuses primarily on providing coverage of E. coli, as well as other common gram-negative uropathogens. Optimal empiric treatment should be safe, effective, affordable, and readily available. Given the lack of patient specific culture results and antimicrobial susceptibility data at the time of antibiotic initiation, empiric therapy is based on knowledge of local E. coli antimicrobial susceptibility patterns. This is especially important when patients are treated in the ED may be lost to follow-up after discharge.

The 2010 IDSA recommended treatment options for cystitis include nitrofurantoin (NTF), fosfomycin, and sulfamethoxazole-trimethoprim (SMZ-TMP), with fluoroquinolones (FQs) and β-lactam antibiotics (BLs) being considered second-line alternatives [15]. While generally considered very effective for UTIs, their significant adverse effect profile impacts FQ prescribing and recommendations for use. FDA warnings advise that these agents should be used for uncomplicated infections, such as cystitis, only when no other options exist [16]. The IDSA recommends using FQ therapy as a first-line option in pyelonephritis if local E. coli susceptibility is greater than 90 % (<10 % resistance) and using SMZ/TMP for cystitis when local resistance rates are below 20 %, highlighting the importance of utilizing local resistance data to drive empiric prescribing [15].

Changes in the prescribing of FQ therapy for UTI treatment after the CDC recommendations to restrict its use to specific situations have been described. In a review of prescribing at a single large academic outpatient treatment center by Bratsman et al., the use of FQ therapy for multiple infections was found to have no significant changes in FQ use despite FDA recommendations [17]. In a review of insurance database claims between 2015 and 2019, Schmiemann reported trends toward improved guideline-directed antimicrobial treatment of UTIs in Germany but cited the need for further improvements. [18]. In a cohort study conducted in the UK, Aryee et al. reported that one in seven culture-confirmed urinary tract infections were treated with discordant antimicrobial agents in 2024 [19]. In a review of antibiotic prescribing for uncomplicated UTI in the IBM® MarketScan® database between 2006 and 2015, Butler et al. reported that 44 % of patients were initially treated with a FQ agent. Improvements in empiric antimicrobial prescribing require knowledge of local susceptibility patterns for common uropathogens, especially E. coli.

The Centers for Disease Control (CDC) encourages antimicrobial stewardship to reduce antimicrobial resistance [20,21]. Hecker et al., Zalmanovich et al., Hudepohl et al., and Jorgensen et al. have reported efforts to minimize the development of resistance via improved empiric treatment [[22], [23], [24], [25]]. The papers emphasized the role of antibiotic stewardship programs, including an electronic order set with audit and feedback. Mixon et al. described the positive effect of providing prescribers with an educational pocket card [26]. Sullivan et al. described focused efforts to reduce the use of fluoroquinolone therapy in the ED through focused order review [27]. Wang et al. described efforts of a [21,28] pharmacist-driven deprescribing program [29].

Following the publication of our original data from a 2011 cohort, a 2021 follow-up evaluation of antimicrobial susceptibility to E. coli in patients treated and discharged from the emergency department (ED) of a community hospital was conducted [8]. After the initial review, microbiology susceptibility data were shared with ED prescribers, as well as subsequent FDA recommendations to avoid using fluoroquinolones for uncomplicated infections when feasible. Our current study reports changes in the susceptibility of urinary pathogens, with an emphasis on Escherichia coli, to commonly prescribed antimicrobial agents for urinary tract infections (FQ, NTN, BL, SMX-TMP), as well as the prescribing patterns for these antibiotics at our institution over a ten-year period.