Antibiotic prescribing for lower UTI in elderly patients in primary care and risk of bloodstream infection: A cohort study using electronic health records in England

Autoři: Laura Shallcross aff001;  Patrick Rockenschaub aff001;  Ruth Blackburn aff001;  Irwin Nazareth aff002;  Nick Freemantle aff003;  Andrew Hayward aff004
Působiště autorů: Institute of Health Informatics, University College London, London, United Kingdom aff001;  Department of Primary Care and Population Health, University College London, London, United Kingdom aff002;  Institute of Clinical Trials and Methodology, University College London, London, United Kingdom aff003;  Institute of Epidemiology & Healthcare, University College London, London, United Kingdom aff004
Vyšlo v časopise: Antibiotic prescribing for lower UTI in elderly patients in primary care and risk of bloodstream infection: A cohort study using electronic health records in England. PLoS Med 17(9): e1003336. doi:10.1371/journal.pmed.1003336
Kategorie: Research Article
doi: 10.1371/journal.pmed.1003336



Research has questioned the safety of delaying or withholding antibiotics for suspected urinary tract infection (UTI) in older patients. We evaluated the association between antibiotic treatment for lower UTI and risk of bloodstream infection (BSI) in adults aged ≥65 years in primary care.

Methods and findings

We analyzed primary care records from patients aged ≥65 years in England with community-onset UTI using the Clinical Practice Research Datalink (2007–2015) linked to Hospital Episode Statistics and census data. The primary outcome was BSI within 60 days, comparing patients treated immediately with antibiotics and those not treated immediately. Crude and adjusted associations between exposure and outcome were estimated using generalized estimating equations.

A total of 147,334 patients were included representing 280,462 episodes of lower UTI. BSI occurred in 0.4% (1,025/244,963) of UTI episodes with immediate antibiotics versus 0.6% (228/35,499) of episodes without immediate antibiotics. After adjusting for patient demographics, year of consultation, comorbidities, smoking status, recent hospitalizations, recent accident and emergency (A&E) attendances, recent antibiotic prescribing, and home visits, the odds of BSI were equivalent in patients who were not treated with antibiotics immediately and those who were treated on the date of their UTI consultation (adjusted odds ratio [aOR] 1.13, 95% CI 0.97–1.32, p-value = 0.105). Delaying or withholding antibiotics was associated with increased odds of death in the subsequent 60 days (aOR 1.17, 95% CI 1.09–1.26, p-value < 0.001), but there was limited evidence that increased deaths were attributable to urinary-source BSI.

Limitations include overlap between the categories of immediate and delayed antibiotic prescribing, residual confounding underlying differences between patients who were/were not treated with antibiotics, and lack of microbiological diagnosis for BSI.


In this study, we observed that delaying or withholding antibiotics in older adults with suspected UTI did not increase patients’ risk of BSI, in contrast with a previous study that analyzed the same dataset, but mortality was increased. Our findings highlight uncertainty around the risks of delaying or withholding antibiotic treatment, which is exacerbated by systematic differences between patients who were and were not treated immediately with antibiotics. Overall, our findings emphasize the need for improved diagnostic/risk prediction strategies to guide antibiotic prescribing for suspected UTI in older adults.

Klíčová slova:

Antibiotic resistance – Antibiotics – Bloodstream infections – Hospitals – Medical risk factors – Primary care – Sepsis – Urinary tract infections


1. Rosello A, Pouwels KB, Domenech DE Cellès M, VAN Kleef E, Hayward AC, Hopkins S, et al. Seasonality of urinary tract infections in the United Kingdom in different age groups: longitudinal analysis of The Health Improvement Network (THIN). Epidemiol Infect. 2018;146:37–45. doi: 10.1017/S095026881700259X 29168442

2. Urinary tract infection (lower): antimicrobial prescribing [Internet]. NICE guideline [NG109]. National Institute of Health and Care Excellence. [cited 2019 May 28]. Available from:

3. Thelwall S, Nsonwu O, Rooney G, Chudasama D, Wasti S, Anselmo J, et al. Annual epidemiological commentary: Gram-negative bacteraemia, MRSA bacteraemia, MSSA bacteraemia and C. difficile infections, up to and including financial year April 2017 to March 2018 [Internet]. Public Health England; 2018 Jul. [cited 2019 May 28]. Available from:

4. Caterino JM, Leininger R, Kline DM, Southerland LT, Khaliqdina S, Baugh CW, et al. Accuracy of Current Diagnostic Criteria for Acute Bacterial Infection in Older Adults in the Emergency Department. J Am Geriatr Soc. 2017;65:1802–1809. doi: 10.1111/jgs.14912 28440855

5. Bengtsson C, Bengtsson U, Björkelund C, Lincoln K, Sigurdsson JA. Bacteriuria in a population sample of women: 24-year follow-up study. Results from the prospective population-based study of women in Gothenburg, Sweden. Scand J Urol Nephrol. 1998;32:284–289. doi: 10.1080/003655998750015467 9764457

6. Wagenlehner FME, Naber KG, Weidner W. Asymptomatic bacteriuria in elderly patients: significance and implications for treatment. Drugs Aging. 2005;22:801–807. doi: 10.2165/00002512-200522100-00001 16245955

7. Devillé WLJM, Yzermans JC, van Duijn NP, Bezemer PD, van der Windt DAWM, Bouter LM. The urine dipstick test useful to rule out infections. A meta-analysis of the accuracy. BMC Urol. 2004;4:4. doi: 10.1186/1471-2490-4-4 15175113

8. Bignardi GE. Risk factors for Clostridium difficile infection. J Hosp Infect. 1998;40:1–15. doi: 10.1016/s0195-6701(98)90019-6 9777516

9. Woodford HJ, George J. Diagnosis and management of urinary tract infection in hospitalized older people. J Am Geriatr Soc. 2009;57:107–114. doi: 10.1111/j.1532-5415.2008.02073.x 19054190

10. Butler CC, Francis N, Thomas-Jones E, Llor C, Bongard E, Moore M, et al. Variations in presentation, management, and patient outcomes of urinary tract infection: a prospective four-country primary care observational cohort study. Br J Gen Pract. 2017;67:e830–e841. doi: 10.3399/bjgp17X693641 29158245

11. Public Health England. English surveillance programme for antimicrobial utilisation and resistance (ESPAUR) report 2018 [Internet]. Public Health England; 2018 Oct. [cited 2019 Apr 17]. Available from:

12. Ahmed H, Farewell D, Jones HM, Francis NA, Paranjothy S, Butler CC. Incidence and antibiotic prescribing for clinically diagnosed urinary tract infection in older adults in UK primary care, 2004–2014. PLoS ONE. 2018;13:e0190521. doi: 10.1371/journal.pone.0190521 29304056

13. Gharbi M, Drysdale JH, Lishman H, Goudie R, Molokhia M, Johnson AP, 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:l525. doi: 10.1136/bmj.l525 30814048

14. Rapid responses: Gharbi et al. (2019) 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. [cited 2019 Jun 12]. Available from:

15. Herrett E, Gallagher AM, Bhaskaran K, Forbes H, Mathur R, van Staa T, et al. Data Resource Profile: Clinical Practice Research Datalink (CPRD). Int J Epidemiol. 2015;44:827–836. doi: 10.1093/ije/dyv098 26050254

16. Chisholm J. The Read clinical classification. BMJ. 1990;300:1092. doi: 10.1136/bmj.300.6732.1092 2344534

17. Shallcross L, Lorencatto F, Fuller C, Tarrant C, West J, Traina R, et al. An interdisciplinary mixed-methods approach to developing antimicrobial stewardship interventions: Protocol for the Preserving Antibiotics through Safe Stewardship (PASS) Research Programme. Wellcome Open Res. 2020;5:8. doi: 10.12688/wellcomeopenres.15554.1 32090173

18. Smieszek T, Pouwels KB, Dolk FCK, Smith DRM, Hopkins S, Sharland M, et al. Potential for reducing inappropriate antibiotic prescribing in English primary care. J Antimicrob Chemother. 2018;73:ii36–ii43. doi: 10.1093/jac/dkx500 29490058

19. Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315:801–810. doi: 10.1001/jama.2016.0287 26903338

20. de Prost N, Razazi K, Brun-Buisson C. Unrevealing culture-negative severe sepsis. Crit Care. 2013;17:1001. doi: 10.1186/cc13022 24074289

21. Bender R, Kuss O, Hildebrandt M, Gehrmann U. Estimating adjusted NNT measures in logistic regression analysis. Stat Med. 2007;26:5586–5595. doi: 10.1002/sim.3061 17879268

22. R Core Team. R: A language and environment for statistical computing [Internet]. Vienna, Austria: Vienna, Austria; 2018. [cited 2019 Mar 11]. Available from:

23. Dolk FCK, Pouwels KB, Smith DRM, Robotham JV, Smieszek T. Antibiotics in primary care in England: which antibiotics are prescribed and for which conditions? J Antimicrob Chemother. 2018;73:ii2–ii10. doi: 10.1093/jac/dkx504 29490062

24. Falagas ME, Kotsantis IK, Vouloumanou EK, Rafailidis PI. Antibiotics versus placebo in the treatment of women with uncomplicated cystitis: a meta-analysis of randomized controlled trials. J Infect. 2009;58:91–102. doi: 10.1016/j.jinf.2008.12.009 19195714

25. Knottnerus BJ, Geerlings SE, Moll van Charante EP, ter Riet G. Women with symptoms of uncomplicated urinary tract infection are often willing to delay antibiotic treatment: a prospective cohort study. BMC Fam Pract. 2013;14:71. doi: 10.1186/1471-2296-14-71 23721260

26. Gágyor I, Bleidorn J, Kochen MM, Schmiemann G, Wegscheider K, Hummers-Pradier E. Ibuprofen versus fosfomycin for uncomplicated urinary tract infection in women: randomised controlled trial. BMJ. 2015;351:h6544. doi: 10.1136/bmj.h6544 26698878

27. Spurling GKP, Del Mar CB, Dooley L, Foxlee R, Farley R. Delayed antibiotics for respiratory infections. Cochrane Database Syst Rev. 2013;CD004417. doi: 10.1002/14651858.CD004417.pub4 23633320

28. Zalmanovici Trestioreanu A, Lador A, Sauerbrun-Cutler M-T, Leibovici L. Antibiotics for asymptomatic bacteriuria. Cochrane Database Syst Rev. 2015;4:CD009534. doi: 10.1002/14651858.CD009534.pub2 25851268

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PLOS Medicine

2020 Číslo 9
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