Older people diagnosed with a urinary tract infection (UTI – and especially men over 85– who are given no or delayed antibiotics were more likely to develop sepsis or to die than those given a prescription for an antibiotic at their initial GP consultation, according to UK general practice research* published online today by the BMJ. The study authors said in the context of an increase of Escherichia coli bloodstream infections in England, they advocated early initiation of recommended first-line antibiotics for UTI in older people. However, an expert commentator called for further research to determine those for whom it would be safe to delay treatment while awaiting investigation, as well as the type of antibiotics to use.
The researchers, led from Imperial College, London, explained that concerns about rising levels of antimicrobial resistance have led to changing patterns of antibiotic prescribing, which they argued means it is now more important than ever to assess UTI management and outcomes. They analysed data from the Clinical Practice Research Datalink (CPRD) primary care records, linked to hospital episode statistics and death records in England, to evaluate the association between antibiotic treatment for UTI and severe adverse outcomes in elderly patients in primary care.
Their data covered 157,264 adults aged at least 65 years who had presented to a GP with at least one diagnosis of suspected or confirmed lower UTI from November 2007 to May 2015. They reported that among 312,896 UTI episodes (in 157,264 unique patients), 7.2% did not have a record of antibiotics being prescribed and 6.2% showed a delay in antibiotic prescribing; 1,539 episodes of bloodstream infection (0.5%) were recorded within 60 days after the initial UTI.
They calculated that the rate of bloodstream infection was significantly higher among those patients not prescribed an antibiotic (2.9%) and those recorded as revisiting the GP 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%). After adjustment for other factors, bloodstream infection was significantly more likely in the deferred antibiotics group (adjusted odds ratio, OR 7.12) and no antibiotics group (OR 8.08) compared with the immediate antibiotics group. In addition, the rate of hospital admission was almost double among cases with no antibiotics (27.0%) and deferred antibiotics (26.8%), compared with those prescribed immediate antibiotics (14.8%); and 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, HR 1.16 and 2.18, respectively). Men older than 85 years were particularly at risk for both bloodstream infection and 60-day all-cause mortality.
The study authors concluded: “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 E. coli bloodstream infections in England, early initiation of recommended first line antibiotics for UTI in the older population is advocated.”
An expert commentator agreed that prompt treatment should be offered to older patients, especially men and those in areas of greater socioeconomic deprivation, as these are the patients most at risk. But he also pointed out** that a practice of 10,000 patients will see one or two patients each year with E. coli-related bloodstream infection, compared with around 1,800 UTI episodes managed in the same period and age group.
He added: “Further research is needed to establish whether treatment should be initiated with a broad or a narrow spectrum antibiotic and to identify those in whom delaying treatment (while awaiting investigation) is safe.”
*Gharbi M, Drysdale JH, Lishman J, et al. Antibiotic management of urinary tract infection in the elderly in primary care and its association with bloodstream infections and all-cause mortality: a population-based cohort study. BMJ 2019; 364: l525. http://dx.doi.org/10.1136/bmj.l525.
**Hay A. Antibiotic prescribing in primary care. BMJ 2019; 364: l780 doi: 10.1136/bmj.l78.