Unplanned Healthcare Encounters in Drug-Resistant Urinary Tract Infections in Emergency Departments

TL;DR

This study found that patients with drug-resistant UTIs in the ED often need additional healthcare visits, especially if they have kidney disease or are given ineffective antibiotics.

Contribution

The study identifies risk factors for unplanned healthcare encounters in patients with ESBL UTIs treated in the ED.

Findings

64% of patients with ESBL UTIs had unplanned healthcare encounters within 30 days.

Chronic kidney disease and use of oral β-lactams were linked to higher risk of unplanned encounters.

Only 25% of lower UTI patients received nitrofurantoin, which was effective in 75% of cases.

Abstract

Introduction

The treatment of extended-spectrum β-lactamase (ESBL)-producing urinary tract infections (UTIs) in the emergency department (ED) is challenging due to the limited oral treatment options available. The purpose of this study was to describe the treatment and outcomes of ESBL UTIs in the ED and to determine risk factors associated with secondary UTI-related unplanned healthcare encounters.

Methods

This was an institutional review board (IRB)-approved, retrospective cohort study of patients discharged from the ED with an ESBL UTI. The primary outcome was any UTI-related unplanned healthcare encounter within 30 days of the index ED visit. Unplanned healthcare encounters included phone/virtual visits, clinic visits, ED visits, and hospitalizations. Patients of ≥18 years of age treated for symptomatic UTI were included. Logistic regression was used to identify exposures independently associated with UTI-related unplanned healthcare encounters.

Results

A total of 162 patients were included, of which 103 (64%) experienced an unplanned healthcare encounter. The most common UTIs were complicated lower (71, 44%), complicated upper (57, 35%), catheter-related (24, 15%), and uncomplicated cystitis (10, 6%). Nitrofurantoin demonstrated to have in vitro activity in 121 (75%) patients, aminoglycosides in 117 (72%) patients, trimethoprim/sulfamethoxazole (TMP/SMX) in 66 (41%) patients, and fluoroquinolones in 62 (38%) patients. Of the 103 patients who experienced an unplanned healthcare encounter, 76 (74%) received inactive empiric antibiotic treatment. Oral β-lactams were most commonly prescribed, accounting for 66 (41%) of all initial prescriptions. Of the 81 patients with lower UTI, only 20 (25%) received a prescription for nitrofurantoin. Factors associated with UTI-related unplanned healthcare encounters included chronic kidney disease (CKD) (adjusted odds ratio {adjOR}, 3.4; 95% confidence interval {CI}, 1.2-9.5) and empiric oral β-lactam use (adjOR, 3.2; 95% CI, 1.5-6.6).

Conclusions

Patients with CKD or who received empiric oral β-lactam treatment more commonly experienced an ESBL UTI-related unplanned healthcare encounter. Prescribing first-line therapy with nitrofurantoin for lower UTI is a potential area for improvement.

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