6 March 2019

Don’t delay antibiotics for UTIs

Clinical Women

So here’s the exception that proves the rule. Urinary tract infections need immediate treatment with antibiotics to avoid an increased risk of sepsis and death.

That’s the quite definitive conclusion from a large retrospective study involving GP data from the UK recently published in the BMJ.

After analysing the records of more than 150,000 patients aged 65 and over presenting to their GP with a suspected or confirmed UTI, the researchers found those whose antibiotic treatment was delayed or deferred were up to eight times more likely to develop sepsis in the following 60 days compared with the group who were given antibiotics from the beginning.

And those patients who were not given antibiotics at all, they were twice as likely to die as their medicated counterparts.

Most of the infections were caused by Escherichia Coli, and trimethoprim or nitrofurantoin were the most common antibiotics prescribed.

As the study showed, sepsis is not a common sequela of UTI, occurring in just half a percent of cases. But the fact remains if antibiotics were delayed or withheld altogether, the incidence jumped to 2.2% and 2.9% respectively, which is significant and totally unnecessary.

Understandably outcomes were worse the older the patient, and men had more adverse outcomes than women, but even accounting for multiple variable factors the basic conclusion remained the same.

“Our study suggests the early initiation of antibiotics for UTI in older high-risk adult populations (especially men aged >85 years) should be recommended to prevent serious complications,” the study authors said.

Of concern to the researchers was the relatively large number of older patients (about 7%) who were diagnosed with a UTI but not treated.

They suggest antimicrobial stewardship programs encouraging more judicious use of antibiotics may be at least, in part, to blame. That, and the risk of elderly patients developing Clostridium difficile infection following antibiotic use.

But while “delayed or deferred” antibiotic treatment was not generally associated with serious adverse outcomes for some self-limiting illnesses, such as upper respiratory tract infections, this study suggests it is not a good idea for UTIs.

“In our study, deferred antibiotics were associated with less severe adverse outcomes than no antibiotics for older adults but still showed a significantly higher risk of mortality compared with immediate antibiotics,” the researchers said.

An accompanying editorial by a UK GP academic says the study highlights one of the many dilemmas that occur in general practice.

“[GPs face] the daily challenge of ensuring that patients who are unlikely to benefit are not treated, whereas those who require antibiotics receive the right class, at the right time, at the right dose, and for the right duration,” he wrote.

And while agreeing with the authors that all older patients with suspected UTI should be treated from day one, he does suggest further research is needed.

Research could help determine the most appropriate antibiotic in this situation, and if there were any particular groups in this 65 and over cohort who it would be safe to leave off antibiotic treatment until the result of the culture and sensitivities were known.

bmj.com/content/bmj/364/bmj.l525.full.pdf

bmj.com/content/364/bmj.l780

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L-F Ng
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4 months 18 days ago

I agree. I offer my community patients two options: a shot in the dark with an 80% chance of success or wait till the sensitivities are scientifically available. Few will take option two and prefer to take the 20% chance that it will not work and a change is needed.

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