Objective To evaluate the association between antibiotic treatment for urinary tract infection (UTI) and severe adverse outcomes in elderly patients in primary care. Design Retrospective population based cohort study. Setting Clinical Practice Research Datalink (2007-15) primary care records linked to hospital episode statistics and death records in England. Participants 157 264 adults aged 65 years or older presenting to a general practitioner with at least one diagnosis of suspected or confirmed lower UTI from November 2007 to May 2015. Main outcome measures Bloodstream infection, hospital admission, and all cause mortality within 60 days after the index UTI diagnosis. Results Among 312 896 UTI episodes (157 264 unique patients), 7.2% (n=22 534) did not have a record of antibiotics being prescribed and 6.2% (n=19 292) showed a delay in antibiotic prescribing. 1539 episodes of bloodstream infection (0.5%) were recorded within 60 days after the initial UTI. The rate of bloodstream infection was significantly higher among those patients not prescribed an antibiotic (2.9%; n=647) and those recorded as revisiting the general practitioner within seven days of the initial consultation for an antibiotic prescription compared with those given a prescription for an antibiotic at the initial consultation (2.2% v 0.2%; P=0.001). After adjustment for covariates, patients were significantly more likely to experience a bloodstream infection in the deferred antibiotics group (adjusted odds ratio 7.12, 95% confidence interval 6.22 to 8.14) and no antibiotics group (8.08, 7.12 to 9.16) compared with the immediate antibiotics group. The number needed to harm (NNH) for occurrence of bloodstream infection was lower (greater risk) for the no antibiotics group (NNH=37) than for the deferred antibiotics group (NNH=51) compared with the immediate antibiotics group. The rate of hospital admissions was about double among cases with no antibiotics (27.0%) and deferred antibiotics (26.8%) compared with those prescribed immediate antibiotics (14.8%; P=0.001). The risk of all cause mortality was significantly higher with deferred antibiotics and no antibiotics than with immediate antibiotics at any time during the 60 days follow-up (adjusted hazard ratio 1.16, 95% confidence interval 1.06 to 1.27 and 2.18, 2.04 to 2.33, respectively). Men older than 85 years were particularly at risk for both bloodstream infection and 60 day all cause mortality. Conclusions In elderly patients with a diagnosis of UTI in primary care, no antibiotics and deferred antibiotics were associated with a significant increase in bloodstream infection and all cause mortality compared with immediate antibiotics. In the context of an increase of Escherichia coli bloodstream infections in England, early initiation of recommended first line antibiotics for UTI in the older population is advocated.

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Objectives To examine the aggregate rates of antibiotic use at population level and compare these rates over time against historical averages to identify the effect of SARS-CoV-2 and the resulting control measures, upon community prescribing. Methods We collected antibiotic prescriptions and physician office visits from January 1, 2016 to July 21, 2020. We calculated monthly prescription rates stratified by sex, age group, profession, diagnosis type and antibiotic class. We looked at monthly prescription rate as a moving average over time. Using interrupted time series analysis method we estimated the changes in prescription rates after March 2020. Results The moving average of overall monthly prescription rates during January to June of 2020 were below the minimum of the historical years’ moving averages (2016-2019). We observed >30% reduction in overall monthly prescription rates in April, May and July of 2020 compared to the same months of 2019. We observed overall monthly prescription rates experienced a significant level change of -12.79 (p < 0.001) after COVID-19 after March 2020, with the greatest level change of -18.02 among 1-4 years (p<0.001). We estimated an average -5.94 (p<0.001) change in RTI-associated monthly prescription rates after March 2020. Overall prescription rates comparing January – July 2019 and their 2020 counterparts showed a decrease in monthly prescribing ranging from -1 to -5 for: amoxicillin, amoxicillin and enzyme inhibitors, azithromycin, clarithromycin and sulfamethoxazole. Conclusion In BC, Canada, overall and RTI-specific monthly antibiotic prescription rates declined significantly during April to July 2020 compared to the same months in pre-pandemic years.