The Benefits and Harms of Antibiotic Prophylaxis for Urinary Tract Infection in Older Adults

Abstract

Background The role of antibiotics in preventing urinary tract infection (UTI) in older adults is unknown. We sought to quantify the benefits and risks of antibiotic prophylaxis among older adults. Methods We conducted a matched cohort study comparing older adults (≥66 years) receiving antibiotic prophylaxis, defined as antibiotic treatment for at least 30 days starting within 30 days of a positive culture, to patients with positive urine cultures that received antibiotic treatment but did not receive prophylaxis. We matched each prophylaxis recipient to 10 non-recipients based on organism, number of positive cultures, and propensity score. Outcomes included 1) emergency department (ED) visit or hospitalization for UTI, sepsis, or bloodstream infection within 1 year; 2) acquisition of antibiotic resistance in urinary tract pathogens; 3) antibiotic-related complications. Results Overall 4.7% (151/3,190) of UTI prophylaxis patients and 3.6% (n=1,092/30,542) controls required an ED visit or hospitalization for UTI, sepsis, or bloodstream infection (Hazard Ratio (HR) 1.33, 95%CI 1.12 to 1.57). Acquisition of antibiotic resistance to any urinary antibiotic (HR 1.31, 95%CI 1.18 to 1.44) and to the specific prophylaxis agent (HR 2.01, 95% CI 1.80 to 2.24) were higher in patients receiving prophylaxis. While the overall risk of antibiotic-related complications was similar between groups (HR 1.08, 95%CI 0.94 to 1.22) the risk of C. difficile and general medication adverse events was higher in prophylaxis recipients (HR 1.56, 95%CI 1.05 to 2.23; HR 1.62, 95%CI 1.11 to 2.29, respectively). Conclusions Among older adults with UTI, the harms of long-term antibiotic prophylaxis may outweigh their benefits.

Antibiotics versus no treatment for asymptomatic bacteriuria in residents of aged care facilities: a systematic review and meta-analysis

“…In another matched cohort study that focused on the prevention of UTIs, older adults (aged ≥66 years) receiving antibiotic prophylaxis were compared with patients who did not receive prophylaxis, and the study had similar findings to this current review. 35 The authors found that long-term antibiotic prophylaxis was associated with higher acquisition of antibiotic resistance to any urinary antibiotic and any agent used for prophylaxis, and increased risk of hospital admission or emergency department visit because of UTI, sepsis, or bloodstream infection compared with the control group.…”

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“…Although the methenamine hippurate group had a 55% higher rate of UTI episodes than the antibiotics group, the absolute difference was just 0.49 UTI episodes per year, which has limited clinical consequence. The risks of long term prophylactic antibiotic treatment have been well recognised in a recent study, 16 which identified the increased risk of antibiotic resistance development in elderly patients receiving this treatment. The authors also described an increased risk of antibiotic associated complications, including Clostridium difficile infection, and concluded that the risks of long term antibiotic prophylaxis might outweigh the benefits in older patients with UTI.…”

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