Empiric antibiotic therapy in urinary tract infection in patients with risk factors for antibiotic resistance in a German emergency department

Abstract

BackgroundThe aim of this study was to identify clinical risk factors for antimicrobial resistances and multidrug resistance (MDR) in urinary tract infections (UTI) in an emergency department in order to improve empirical therapy.MethodsUTI cases from an emergency department (ED) during January 2013 and June 2015 were analyzed. Differences between patients with and without resistances towards Ciprofloxacin, Piperacillin with Tazobactam (Pip/taz), Gentamicin, Cefuroxime, Cefpodoxime and Ceftazidime were analyzed with Fisher’s exact tests. Results were used to identify risk factors with logistic regression modelling. Susceptibility rates were analyzed in relation to risk factors.ResultsOne hundred thirty-seven of four hundred sixty-nine patients who met the criteria of UTI had a positive urine culture. An MDR pathogen was found in 36.5% of these. Overall susceptibility was less than 85% for standard antimicrobial agents. Logistic regression identified residence in nursing homes, male gender, hospitalization within the last 30 days, renal transplantation, antibiotic treatment within the last 30 days, indwelling urinary catheter and recurrent UTI as risk factors for MDR or any of these resistances. For patients with no risk factors Ciprofloxacin had 90%, Pip/taz 88%, Gentamicin 95%, Cefuroxime 98%, Cefpodoxime 98% and Ceftazidime 100% susceptibility. For patients with 1 risk factor Ciprofloxacin had 80%, Pip/taz 80%, Gentamicin 88%, Cefuroxime 78%, Cefpodoxime 78% and Ceftazidime 83% susceptibility. For 2 or more risk factors Ciprofloxacin drops its susceptibility to 52%, Cefuroxime to 54% and Cefpodoxime to 61%. Pip/taz, Gentamicin and Ceftazidime remain at 75% and 77%, respectively.ConclusionsWe identified several risk factors for resistances and MDR in UTI. Susceptibility towards antimicrobials depends on these risk factors. With no risk factor cephalosporins seem to be the best choice for empiric therapy, but in patients with risk factors the beta-lactam penicillin Piperacillin with Tazobactam is an equal or better choice compared to fluoroquinolones, cephalosporins or gentamicin. This study highlights the importance of monitoring local resistance rates and its risk factors in order to improve empiric therapy in a local environment.

Inadequate empirical antimicrobial treatment in older people with bacteremic urinary tract infection who reside in nursing homes: A multicenter prospective observational study

“…These findings are in accordance with those previously described for sepsis from different sources, and have been attributed to infections caused by more aggressive microorganisms and with higher resistance to antibiotics in nursing home patients, which are similar to those found in nosocomial infections …”

“…The overall percentage of IEAT in the present series was 27.6%, similar to that previously described for UTI in older people, but in the group of patients coming from nursing homes, this percentage increased to 40% . This is in line with other studies that show nursing homes as a risk factor for IEAT in UTI . The above findings could be partly explained by the high percentage of ESBL‐producing Enterobacteriaceae , although other factors, such as the empiric use of quinolones in 25% of our patients, were also associated with IEAT in almost half the patients.…”

“…These findings are in accordance with those previously described for sepsis from different sources, 5 and have been attributed to infections caused by more aggressive microorganisms and with higher resistance to antibiotics in nursing home patients, which are similar to those found in nosocomial infections. 6,8,15,16 In line with that previously published, no differences were found between the etiology of UTI in nursing home patients and community-dwelling patients. E. coli was the most common isolated microorganism, both in patients from nursing homes and the community, and accounts for 68.5% of the total of the microorganism.…”

“…10 This is in line with other studies that show nursing homes as a risk factor for IEAT in UTI. 8,9 The above findings could be partly explained by the high percentage of ESBL-producing Enterobacteriaceae, although other factors, such as the empiric use of quinolones in 25% of our patients, were also associated with IEAT in almost half the patients. The present results are consistent with several studies that reflect a lower susceptibility of E. coli to quinolones, linking it to healthcare-related infections, old age, comorbidities and previous accumulated use of quinolones.…”

“…However, previous studies showed that their etiology and patterns of resistance are more similar to UTI acquired in hospital than to community-acquired UTI. 6,7 Furthermore, other studies have identified nursing homes as a risk factor for inadequate empiric antibiotic therapy (IEAT) in patients admitted to hospital with UTI, 8,9 although there are other findings that differ. 10 The aim of the present study was to determine the rate of inadequate empirical antimicrobial treatment in older nursing home residents with bacteremic urinary tract infection and its influence on prognosis.…”