Start antibiotics early in elderly with urinary infection to prevent sepsis

Start antibiotics as soon as possible after diagnosis of urinary infection in the elderly to prevent sepsis risk. Delaying or withholding antibiotics due to fear of developing antimicrobial resistance in such patients may be dangerous and appears to be associated with higher risk of sepsis and death, finds a study published by The BMJ today.

Sepsis is a potentially life-threatening condition caused by the body's response to an infection. The body normally releases chemicals into the bloodstream to fight an infection. Sepsis occurs when the body's response to these chemicals is out of balance, triggering changes that can damage multiple organ systems.If sepsis progresses to septic shock, blood pressure drops dramatically. This may lead to death.

Urinary tract infection (UTI) is the most common bacterial infection in older patients where antibiotics are needed. But concerns about the spread of antibiotic resistance have led to reductions in antibiotic use in England. This may eventually harm vulnerable older patients who are already more likely to develop UTI-related complications, and there is a lack of good evidence about the treatment of UTIs in primary care.

So a team of UK researchers set out to assess approaches to antibiotic prescribing and subsequent clinical outcomes in elderly patients.

They used primary care data linked to hospital and mortality records across England to analyse over 300,000 UTIs among more than 150,000 patients aged 65 years or older between 2007 and 2015.

The average age of participants was 77 years, most (79%) cases were female, and follow-up was for 60 days after diagnosis.

The researchers then compared outcomes for the 87% of patients who were prescribed immediate antibiotics (on the day of diagnosis), the 6% who had deferred antibiotics (prescription within seven days), and the 7% who had no antibiotics (no record of a prescription within seven days).

After taking account of potentially influential factors, bloodstream infections and mortality rates were significantly higher in the groups with no and with deferred prescriptions, compared with immediate prescriptions

The researchers estimate that on average for every 37 patients not given antibiotics and for every 51 patients whose antibiotic treatment was deferred, one case of sepsis would occur that would not have been seen with immediate antibiotics.

They also found that the rate of hospital admissions was around double (27%) in patients with no and with deferred prescriptions, compared with immediate prescriptions (15%).

Older men, especially those aged over 85 years, and those living in more deprived areas were most at risk.

This is an observational study, and as such, can't establish cause, and the researchers cannot rule out the possibility that unmeasured factors or missing data may have affected the results.

Nevertheless, they say their findings suggest that GPs "consider early prescription of antibiotics for this vulnerable group of older adults, in view of their increased susceptibility to sepsis following UTI and despite a growing pressure to reduce inappropriate antibiotic use."

Particular care is needed for the management of older men, and those in deprived communities, they conclude.

In a linked editorial, Alastair Hay at the University of Bristol says the implications of this study "are likely to be more nuanced than primary care doctors risking the health of older adults to meet targets for antimicrobial stewardship."

However, he agrees that prompt treatment should be offered to older patients, especially men and those living in areas of greater socioeconomic deprivation, and says 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."