London, UK—Delaying antibiotics for elderly patients with urinary tract infections (UTIs) puts them at increased risk of sepsis and death, according to a new study.
The report in The BMJ reveals results of an observational study of more than 150,000 older patients in England. Patients who received antibiotics in the days following diagnosis or none at all were compared to those who were given the drugs immediately.
Researchers at Imperial College London and Public Health England suggest the results should help clinicians concerned about overuse of antibiotics determine when it is okay to defer treatment to see if symptoms improve on their own and when they must respond quickly.
“Current national guidelines for GPs recommend they should ask patients about the severity of their symptoms, discuss possible self-care, such as drinking plenty of water to avoid dehydration and taking paracetamol or ibuprofen for pain relief, and consider a back-up antibiotic prescription to be used if symptoms worsen or have not improved after 48 hours,” explained lead author Myriam Garbi, PharmD, MPH, PhD, of Imperial’s School of Public Health, discussing policy in the United Kingdom. “This is to avoid antibiotic overuse, as sometimes UTIs can get better without medication. However, our research suggests antibiotics should not be delayed in elderly patients.”
Records from 157,264 patients older than age 65 years across England who had been diagnosed with a suspected or confirmed UTI were reviewed for the study. Of those, 87% of patients had been prescribed antibiotics immediately, 6% had antibiotics delayed up to 7 days, and 7% received no antibiotics at all.
Results indicate that, among 312,896 UTI episodes involving the participants, 1,539 episodes of bloodstream infection (0.5%) were recorded within 60 days after the initial UTI. Researchers point out that the rate of bloodstream infection was significantly higher among those patients not prescribed an antibiotic, 2.9%, and those recorded as returning to their doctor within 7 days of the initial consultation for an antibiotic prescription versus those given a prescription for an antibiotic at the initial visit—2.2% versus 0.2%.
After adjustment for covariates, patients were found to be significantly more likely to experience a bloodstream infection in the deferred antibiotics group (adjusted odds ratio 7.12, 95% confidence interval 6.22 -8.14) and no-antibiotics group (8.08, 7.12- 9.16) compared with the immediate-antibiotics group.
The study team also notes that the number needed to harm (NNH) for occurrence of bloodstream infection was lower for the no-antibiotics group (NNH = 37), representing greater risk, than for the deferred-antibiotics group (NNH = 51) compared with the immediate-antibiotics group. At the same time, the rate of hospital admissions was about double among cases with no antibiotics (27.0%) and deferred antibiotics (26.8%) compared with those prescribed immediate antibiotics (14.8%; P = .001).
Even more disturbing, according to the authors, 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 of follow-up (adjusted hazard ratio 1.16, 95% confidence interval [CI], 1.06-1.27 and 2.18, 2.04-2.33, respectively). Especially at risk for both bloodstream infection and 60-day all-cause mortality were men older than age 85 years, they said.
“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,” study authors write. “In the context of an increase of Escherichia coli bloodstream infections in England, early initiation of recommended first line antibiotics for UTI in the older population is advocated.”
“Although antibiotic prescribing must be controlled to help combat the increasing problem of antibiotic resistance, our study suggests early use of antibiotics in elderly patients with UTIs is the safest approach,” added senior author Paul Alyin, MBChB.
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The report in The BMJ reveals results of an observational study of more than 150,000 older patients in England. Patients who received antibiotics in the days following diagnosis or none at all were compared to those who were given the drugs immediately.
Researchers at Imperial College London and Public Health England suggest the results should help clinicians concerned about overuse of antibiotics determine when it is okay to defer treatment to see if symptoms improve on their own and when they must respond quickly.
“Current national guidelines for GPs recommend they should ask patients about the severity of their symptoms, discuss possible self-care, such as drinking plenty of water to avoid dehydration and taking paracetamol or ibuprofen for pain relief, and consider a back-up antibiotic prescription to be used if symptoms worsen or have not improved after 48 hours,” explained lead author Myriam Garbi, PharmD, MPH, PhD, of Imperial’s School of Public Health, discussing policy in the United Kingdom. “This is to avoid antibiotic overuse, as sometimes UTIs can get better without medication. However, our research suggests antibiotics should not be delayed in elderly patients.”
Records from 157,264 patients older than age 65 years across England who had been diagnosed with a suspected or confirmed UTI were reviewed for the study. Of those, 87% of patients had been prescribed antibiotics immediately, 6% had antibiotics delayed up to 7 days, and 7% received no antibiotics at all.
Results indicate that, among 312,896 UTI episodes involving the participants, 1,539 episodes of bloodstream infection (0.5%) were recorded within 60 days after the initial UTI. Researchers point out that the rate of bloodstream infection was significantly higher among those patients not prescribed an antibiotic, 2.9%, and those recorded as returning to their doctor within 7 days of the initial consultation for an antibiotic prescription versus those given a prescription for an antibiotic at the initial visit—2.2% versus 0.2%.
After adjustment for covariates, patients were found to be significantly more likely to experience a bloodstream infection in the deferred antibiotics group (adjusted odds ratio 7.12, 95% confidence interval 6.22 -8.14) and no-antibiotics group (8.08, 7.12- 9.16) compared with the immediate-antibiotics group.
The study team also notes that the number needed to harm (NNH) for occurrence of bloodstream infection was lower for the no-antibiotics group (NNH = 37), representing greater risk, than for the deferred-antibiotics group (NNH = 51) compared with the immediate-antibiotics group. At the same time, the rate of hospital admissions was about double among cases with no antibiotics (27.0%) and deferred antibiotics (26.8%) compared with those prescribed immediate antibiotics (14.8%; P = .001).
Even more disturbing, according to the authors, 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 of follow-up (adjusted hazard ratio 1.16, 95% confidence interval [CI], 1.06-1.27 and 2.18, 2.04-2.33, respectively). Especially at risk for both bloodstream infection and 60-day all-cause mortality were men older than age 85 years, they said.
“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,” study authors write. “In the context of an increase of Escherichia coli bloodstream infections in England, early initiation of recommended first line antibiotics for UTI in the older population is advocated.”
“Although antibiotic prescribing must be controlled to help combat the increasing problem of antibiotic resistance, our study suggests early use of antibiotics in elderly patients with UTIs is the safest approach,” added senior author Paul Alyin, MBChB.
« Click here to return to Weekly News Update.
