Clinical Risk Scores to Predict Nonsusceptibility to Trimethoprim-Sulfamethoxazole, Fluoroquinolone, Nitrofurantoin, and Third-Generation Cephalosporin Among Adult Outpatient Episodes of Complicated Urinary Tract Infection

Abstract

Background Clinical risk scores were developed to estimate the risk of adult outpatients having a complicated urinary tract infection (cUTI) that was non-susceptible to trimethoprim-sulfamethoxazole (TMP-SMX), fluoroquinolone, nitrofurantoin, or third-generation cephalosporins (3-GC) based on variables available on clinical presentation. Methods A retrospective cohort study (12/1/2017-12/31/2020) was performed among adult Kaiser Permanente Southern California members with an outpatient cUTI. Separate risk scores were developed for TMP-SMX, fluoroquinolone, nitrofurantoin, and 3-GC. The models were translated into risk scores to quantify the likelihood of non-susceptibility based on the presence of final model covariates in a given cUTI outpatient. Results A total of 30,450 cUTIs (26,326 patients) met the study criteria. Non-susceptibility to TMP-SMX, fluoroquinolones, nitrofurantoin, and 3-GC were 37%, 20%, 27%, and 24%, respectively. Receipt of prior antibiotics was the most important predictor across all models. The risk of non-susceptibility in the TMP-SMX model exceeded 20% in the absence of any risk factors, suggesting that empiric use of TMP-SMX may not be advisable. For fluoroquinolone, nitrofurantoin, or 3-GC, clinical risk scores of 10, 7, and 11, respectively, predicted a ≥20% estimated probability of non-susceptibility in the models that included cumulative number of prior antibiotics at model entry. This finding suggests caution should be used when considering these agents empirically in patients who have several risk factors present in a given model(s) at presentation. Conclusions We developed high-performing parsimonious risk scores to facilitate empiric treatment selection for adult cUTI outpatients in the critical period between infection presentation and availability of susceptibility results.