Early Use of Antibiotics May Be Safest for UTI in Elderly

By Anne Harding

NEW YORK (Reuters Health) - Delaying or skipping antibiotics for elderly patients with urinary-tract infections (UTI) may boost their risk of bloodstream infection and all-cause mortality, new findings show.

"There appears to be a link between a delay in antibiotic prescribing for urinary tract infections in elderly patients and an increased risk of sepsis and death, and that was particularly in older men, especially those aged 85 years and older," Dr. Paul Aylin of Imperial College London in the U.K. told Reuters Health via Skype. "Our study suggests that in elderly patients with urinary-tract infections, early use of antibiotics is the safest approach."

Guidelines and antimicrobial stewardship programs have led to a drop in antibiotic prescribing across the U.K. from 2013 to 2017, Dr. Aylin and his team note in The BMJ, online February 28. However, they note, older people are at increased risk of complications from UTI, so reducing antibiotic use in this population could be harmful.

To investigate, the researchers looked at data from the UK's Clinical Practice Research Datalink on more than 157,000 adults 65 and older presenting to a general practitioner for suspected or confirmed UTI, with nearly 312,900 episodes in total.

Antibiotics were delayed in 6.2% of UTI episodes and not prescribed in 7.2%. Patients over 85, living in economically deprived areas and with more comorbidities were more likely to receive deferred antibiotics or no antibiotics.

In the 60 days after the first UTI, there were 1,539 cases (0.5%) of bloodstream infection.

Sepsis incidence was 2.9% for patients not prescribed an antibiotic, 2.2% for those who returned within a week for an antibiotic prescription, and 0.2% for those who received a prescription at their first visit.

The adjusted odds ratio for bloodstream infection was 7.12 with deferred antibiotics compared with early antibiotics, and 8.08 with no antibiotics, both statistically significant increases. The number needed to harm (NNH) for sepsis was 37 with no antibiotics and 51 with delayed antibiotics.

Hospital admission rates were 27% with no antibiotics, 26.8% with deferred antibiotics, and 14.8% with immediate antibiotics (P=0.001).

Overall, 2% of patients died within 60 days of visiting their primary-care physician; 60-day mortality was 5.4% with no antibiotics, 2.8% with deferred antibiotics and 1.6% with immediate antibiotics.

The adjusted hazard ratio for 60-day mortality was 1.16 with deferred antibiotics and 2.18 for no antibiotics compared to early antibiotics, also significant. The NNH for 60-day mortality was 27 with no antibiotics and 83 with deferred antibiotics.

"We have no evidence to suggest that antibiotic use has actually been reduced in vulnerable, complex elderly patients," Dr. Aylin said. "One of the limitations of this particular study is that we were unable to make a causal association between antibiotic prescribing and outcomes. The patients who didn't get antibiotics may be quite different to the patients who did get antibiotics."

Nevertheless, he added, "our study highlights the importance of taking age into account when making decisions about antibiotic prescribing."

In an editorial, Dr. Alastair D. Hay of the University of Bristol, UK, writes: "Prompt treatment should be offered to older patients, men (who are at higher risk than women), and those living in areas of greater socioeconomic deprivation who are at the highest risk of bloodstream infections. 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."

SOURCE: https://bit.ly/2TgD8ki and https://bit.ly/2ISFVLR

BMJ 2019.

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