Infectious Disease

The harms of UTI prophylaxis outweigh the advantages in older adults

March 03, 2021

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Older adult patients who received antibiotic prophylaxis for urinary tract infections were at increased risk of hospitalization, sepsis, and bloodstream infections, according to a study of clinical infectious diseases.

“Older patients have a higher risk of infection than younger patients, which is in large part due to immunodeficiency. At the same time, however, they are more prone to antibiotic harm such as adverse events, drug interactions, and Clostridioides difficile infections. Therefore, it is particularly important in this population to evaluate both the risks and the benefits of antibiotics. ” Bradley YY Langford, PharmD, a pharmacist advisor at Public Health Ontario, said Healio.

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Langford BJ et al. Clin Infect Dis. 2021; doi: 10.1093 / cid / ciab116.

“We know that UTIs are one of the most common infections leading to hospitalization, and recurring UTIs are particularly stressful, so long-term antibiotic prophylaxis is often used,” Langford said. “Although many studies have shown UTI prophylaxis to be associated with a reduced risk of recurring UTIs, these benefits are less certain in older adults. So, we wanted to see if we could better understand the risks and benefits of UTI prophylaxis in this population. “

Langford and colleagues conducted a coordinated cohort study comparing 3,190 older adults 66 years of age and older who received antibiotic prophylaxis with patients with positive urine cultures who received antibiotic treatment but received no prophylaxis. Outcomes included an ED visit or hospitalization for urinary tract infections, sepsis, or bloodstream infections within a year, the acquisition of antibiotic resistance to urinary tract pathogens, and antibiotic-related complications.

Bradley YY Langford

Overall, antibiotic prophylaxis was associated with a 1.3-fold increase in the risk of hospitalization or an ED visit for urinary tract infections, sepsis, and / or bloodstream infections – 4.7% of patients receiving urinary tract infusion prophylaxis and 3.6% of controls required an ED visit or hospitalization for UTI sepsis or bloodstream infection (HR = 1.33; 95% CI, 1.12-1.57).

In addition, the acquisition of antibiotic resistance to any urinary antibiotic (HR = 1.31; 95% CI, 1.18-1.44) and to the specific prophylactic agent (HR = 2.01; 95% CI, 1.80-2 , 24) is higher in patients receiving prophylaxis. The researchers found that although the overall risk of antibiotic-related complications was similar between groups (HR = 1.08; 95% CI, 0.94-1.22), the risk of adverse events in C. difficile and general Medication in recipients of prophylaxis was higher (HR =) 1.56; 95% CI, 1.05-2.23 vs. HR = 1.62; 95% CI, 1.11-2.29).

Langford said there is a possibility that these differences are due to underlying differences between patients receiving prophylaxis and those who are not. The possible effects of antibiotics on the protective flora are, however, a “more fascinating” explanation.

“It is possible that antibiotic prophylaxis disrupts the local gastrointestinal and vaginal flora and predisposes patients to colonization with more pathogenic and / or more resistant strains of organisms,” he said.

“We hope this study will encourage clinicians to better understand the potential harms of UTI antibiotic prophylaxis as they decide on treatment and discuss the risks and benefits with patients and their families,” said Langford. “As shown in our study and other previous studies evaluating UTI prophylaxis, prolonged use of antibiotics selects antimicrobial-resistant organisms, which can make management of subsequent symptomatic episodes difficult and, as such, lead to poorer patient outcomes.”

Even so, Langford said that UTI prophylaxis may still play a role in older adults, especially those with frequent symptomatic urinary tract infections and those with severe symptoms. “However, the results of our study could help doctors consider other measures (e.g. vaginal estrogens, acute on-demand treatment) before long-term prophylaxis. “

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