Immediate Antibiotic Prescription for UTI in Older Patients Increases Survival

Prospective audit allows antibiotic stewards to engage the prescribing clinician after the antibiotic has been used, typically after two or three days, to optimize antibiotic treatments.
Prospective audit allows antibiotic stewards to engage the prescribing clinician after the antibiotic has been used, typically after two or three days, to optimize antibiotic treatments.
Patients aged >65 years with a UTI may have an increased risk for septicemia and death within 60 days if antibiotic treatment is deferred or not prescribed.

Patients older than 65 years with a diagnosis of urinary tract infection (UTI) may have a significantly increased risk for bloodstream infection and death within 60 days when antibiotic treatment was either deferred or not prescribed, according to a study published in the British Medical Journal.

In the older population (age >65 years), UTIs are the most common bacterial infection, wherein Escherichia coli is the most common uropathogen. UTI is also the second most common diagnosis in which empiric antibiotics are prescribed in both primary and secondary care. For a suspected UTI, more than 50% of the antibiotics prescribed are considered unnecessary in older adults. As a result of this and the spread of antibiotic resistance, national programs have reduced antibiotic use in primary care. However, the decline in antibiotic use may harm vulnerable older populations that are already at an increased risk for UTI-related complications and bloodstream infection. Therefore, more evidence is needed regarding initial treatment of UTI primary care including an assessment of prescribing approaches (no, deferred, and immediate antibiotics) and their corresponding clinical outcome. This retrospective, population-based cohort study evaluated the association between antibiotic treatment for UTI and severe adverse events in elderly patients in primary care.

Using the Clinical Practice Research Datalink from 2007 to 2015, primary care records and death records in England were collected for 157,264 adults aged 65 years or older who were seen by a general practitioner with at least 1 diagnosis of suspected or confirmed lower UTI. The main outcome measures of this study were bloodstream infection, hospital admission, and all-cause mortality within 60 days after the index UTI diagnosis.

Demographics of the participants studied included a mean age of 76.7 years, 78.8% were women, 40.3% originated from the south of England, 28.9% were from the most deprived areas, and 22.0% had recurrent UTIs. Patients were divided into 3 groups: no antibiotics prescribed within 7 days of UTI diagnosis, deferred antibiotics that were prescribed within 7 days to allow for the natural resolution of the disease both not on the initial UTI diagnosis day, and immediate antibiotics wherein patients were prescribed an antibiotic at UTI diagnosis.

The risk for bloodstream infection developing within 60 days was higher in both the deferred antibiotic group (7-fold increase) and the no antibiotics group (8-fold increase) compared with the immediate antibiotics group. Further, the number needed to harm (NNH) for bloodstream infection when compared with immediate antibiotics was lower with no antibiotics (NNH=37) than with deferred antibiotics (NHH=51). In addition, when compared with those in the immediate antibiotics group, patients in the no antibiotics group were 2 times more likely to die and patients in the deferred antibiotics group were 1.16 times more likely to die during the 60 days after UTI. The NHH estimate for death was higher in the deferred antibiotics group (NNH=83) than in the no antibiotics group (NNH=27). In the group that was prescribed immediate antibiotics, nitrofurantoin provided a significant increase of the 60-day survival compared with trimethoprim. Men older than 85 years of age were at particular risk for both 60-day all-cause mortality and bloodstream infection.

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Overall, the study authors concluded that, “Our study suggests the early initiation of antibiotics for UTI in older high risk adult populations (especially men aged >85 years) should be recommended to prevent serious complications.”


Gharbi M, Drysdale JH, Lishman H, et al. Antibiotic management of urinary tract infection in elderly patients in primary care and its association with bloodstream infections and all cause mortality: population based cohort study. BMJ .2019;364:1525.