Antibiotic prophylaxis for UTIs in elderly patients associated with an increased risk of ED visit or hospitalization

1. Among older adults with urinary tract infections, antibiotic prophylaxis was associated with an increased risk of ED visit or hospitalization for UTI, sepsis, or bacteremia.

Evidence Level Rating: 2 (Good)

Urinary tract infections (UTI) are the most common bacterial infections prompting the utilization of health care services. They exert a significant burden on patients and providers, particularly for older adults, with the threat of bacteremia and sepsis. Some patients with recurrent UTIs are managed with prophylactic antibiotics to reduce the incidence of repeat infection; however, the evidence for this strategy with regards to more severe outcome measures, particularly among older adults, is unknown. This retrospective cohort study compared older adults ≥ 66 years receiving antibiotic prophylaxis for UTI – defined as duration ≥ 30 days following a positive urine culture – to matched patients with a positive urine culture who did not receive prophylaxis. The primary efficacy outcome was a composite of ED visits or hospitalization for UTI, sepsis, or bacteremia within 30 days to one year after the positive urine culture. The primary harm outcome was detection of a repeat urinary isolate resistant to an antibacterial agent to which it was initially susceptible. Matching yielded 3,190 UTI prophylaxis patients and 30,542 control patients. It was found that 4.7% of the prophylaxis cohort and 3.6% of the control cohort required ED visits or hospitalization for UTI, sepsis, or bacteremia (HR 1.33, 95% CI 1.12 to 1.57); this increased utilization was particularly pronounced among patients less than 80 years of age (HR 1.66, 95% CI 1.33 to 2.06). Furthermore, the acquisition of antibiotic resistance to any agent was more pronounced in the prophylaxis cohort (HR 1.31, 95% CI 1.18 to 1.44). Finally, antibiotic-associated harm was more common among patients in the prophylaxis cohort, with the risk of C. difficile infection and medication adverse side effects being significantly higher. In all, among older adults with a history of positive urine culture, antibiotic prophylaxis was associated with an increased risk of harm as well as an increased risk of ED visit or hospitalization for UTI, sepsis, or bacteremia, suggesting that the harms of UTI prophylaxis in this cohort may outweigh the benefits.

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