Antibiotic management of urinary tract infection in elderly patients in primary care and its association with bloodstream infections and all cause mortality: population based cohort study

Abstract

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.

Advanced Age is not a Risk Factor for Mortality in Patients with Bacteremia Caused by Extended-Spectrum β-Lactamase-Producing Organisms: a Multicenter Cohort Study

“…We hypothesized that patients aged ≥85 years would have a high mortality rate due to increasing immunosenescence. Although there are no data suggesting that "elderly" should be defined as age ≥85 years in patients with BSI caused by ESBL-producing Enterobacteriaceae, patients in this age group who develop Clostridium difficile or a urinary tract infection (UTI) are reported to be at higher risk of a complicated course (13,14). The high mortality rate in these patients might justify empirical use of carbapenem antibiotics.…”

Antibiotic prescribing for lower UTI in elderly patients in primary care and risk of bloodstream infection: a cohort study using electronic health records

“…These patients arguably have the most to gain from prudent antibiotic prescribing, due to their increased risk of adverse outcomes related to antibiotic use 23 and high prevalence of asymptomatic bacteriuria. 6 The major barrier to delaying or withholding antibiotics in these individuals is the risk of UTI-related complications, as reported by Gharbi et al 12 Our analysis, and concerns raised by other research groups, call these findings into question. We find no evidence of an association between delaying or withholding antibiotics and sepsis, but some evidence of increased mortality.…”

“…The study population comprised patients who consulted for a new episode of lower UTI that originated in the community. UTI episodes were identified from the primary care or linked hospital record using previously published codelists 12 ( Supplementary Table 1) based on Read codes and International Classification of Diseases 10 th revision (ICD-10).…”

“…on the date of their first UTI consultation). 12 Delaying or withholding antibiotics was also associated with a statistically significant increase in 60 day mortality. Gharbi et al are the first to address this important research question and their findings are therefore likely to have a significant influence on policy and clinical practice, for example by reducing GPs willingness to consider the use of potentially beneficial strategies such as delayed prescribing.…”

Too much medicine: symptoms matter

“…In symptom driven medicine, patients are asking for our help; in anticipatory medicine, they are being told they need our help. Symptomatic people are more likely to have adverse outcomes (such as sepsis and death in the cohort with urinary tract infection5). Plus, the presence of symptoms means there is room to get better.…”