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


Autoři: Laura Shallcross aff001;  Patrick Rockenschaub aff001;  Ruth Blackburn aff001;  Irwin Nazareth aff002;  Nick Freemantle aff003;  Andrew Hayward aff004
Působiště autorů: Institute of Health Informatics, University College London, London, United Kingdom aff001;  Department of Primary Care and Population Health, University College London, London, United Kingdom aff002;  Institute of Clinical Trials and Methodology, University College London, London, United Kingdom aff003;  Institute of Epidemiology & Healthcare, University College London, London, United Kingdom aff004
Vyšlo v časopise: Antibiotic prescribing for lower UTI in elderly patients in primary care and risk of bloodstream infection: A cohort study using electronic health records in England. PLoS Med 17(9): e32767. doi:10.1371/journal.pmed.1003336
Kategorie: Research Article
doi: 10.1371/journal.pmed.1003336

Souhrn

Background

Research has questioned the safety of delaying or withholding antibiotics for suspected urinary tract infection (UTI) in older patients. We evaluated the association between antibiotic treatment for lower UTI and risk of bloodstream infection (BSI) in adults aged ≥65 years in primary care.

Methods and findings

We analyzed primary care records from patients aged ≥65 years in England with community-onset UTI using the Clinical Practice Research Datalink (2007–2015) linked to Hospital Episode Statistics and census data. The primary outcome was BSI within 60 days, comparing patients treated immediately with antibiotics and those not treated immediately. Crude and adjusted associations between exposure and outcome were estimated using generalized estimating equations.

A total of 147,334 patients were included representing 280,462 episodes of lower UTI. BSI occurred in 0.4% (1,025/244,963) of UTI episodes with immediate antibiotics versus 0.6% (228/35,499) of episodes without immediate antibiotics. After adjusting for patient demographics, year of consultation, comorbidities, smoking status, recent hospitalizations, recent accident and emergency (A&E) attendances, recent antibiotic prescribing, and home visits, the odds of BSI were equivalent in patients who were not treated with antibiotics immediately and those who were treated on the date of their UTI consultation (adjusted odds ratio [aOR] 1.13, 95% CI 0.97–1.32, p-value = 0.105). Delaying or withholding antibiotics was associated with increased odds of death in the subsequent 60 days (aOR 1.17, 95% CI 1.09–1.26, p-value < 0.001), but there was limited evidence that increased deaths were attributable to urinary-source BSI.

Limitations include overlap between the categories of immediate and delayed antibiotic prescribing, residual confounding underlying differences between patients who were/were not treated with antibiotics, and lack of microbiological diagnosis for BSI.

Conclusions

In this study, we observed that delaying or withholding antibiotics in older adults with suspected UTI did not increase patients’ risk of BSI, in contrast with a previous study that analyzed the same dataset, but mortality was increased. Our findings highlight uncertainty around the risks of delaying or withholding antibiotic treatment, which is exacerbated by systematic differences between patients who were and were not treated immediately with antibiotics. Overall, our findings emphasize the need for improved diagnostic/risk prediction strategies to guide antibiotic prescribing for suspected UTI in older adults.

Klíčová slova:

Antibiotic resistance – Antibiotics – Bloodstream infections – Hospitals – Medical risk factors – Primary care – Sepsis – Urinary tract infections


Zdroje

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PLOS Medicine


2020 Číslo 9

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