Why is antimicrobial de-escalation under-prescribed for urinary tract infections?

• Published in: Infection Vol. 41; no. 1; pp. 211 - 214
• Main Authors: Duchêne, E., Montassier, E., Boutoille, D., Caillon, J., Potel, G., Batard, E.
• Format: Journal Article
• Language: English
• Published: Berlin/Heidelberg Springer-Verlag 01.02.2013; Springer Nature B.V
• Subjects: Adult; Aged; Aged, 80 and over; Anti-Bacterial Agents - administration & dosage; Anti-Bacterial Agents - therapeutic use; Antibacterial agents; Brief Report; Community-Acquired Infections - drug therapy; E coli; Escherichia coli; Family Medicine; Female; General Practice; Humans; Infectious Diseases; Inpatients; Internal Medicine; Male; Medicine; Medicine & Public Health; Middle Aged; Retrospective Studies; Treatment Outcome; Urinary Tract Infections - drug therapy; Young Adult; de-escalation; Cotrimoxazole; Urinary tract infection; Amoxicillin; Co-amoxiclav
• ISSN: 0300-8126; 1439-0973
• DOI: 10.1007/s15010-012-0359-x

Purpose To assess the frequency of de-escalation in inpatients treated for community-acquired urinary tract infection and the frequency of conditions legitimating not de-escalating therapy. Methods A retrospective study of inpatients (age >15 years) at a large academic hospital who were empirically treated for urinary tract infections due to Escherichia coli susceptible to at least one of the following antibacterial agents: amoxicillin, co-amoxiclav, and cotrimoxazole. De-escalation was defined as the replacement of the empirical broad-spectrum therapy by amoxicillin, co-amoxiclav, or cotrimoxazole. Results Eighty patients were included. De-escalation was prescribed for 32 of 69 patients for whom it was possible from both a bacteriological and clinical point of view (46 %, 95 % CI, 34–59 %). Initial treatment was switched to amoxicillin ( n  = 21), co-amoxiclav ( n  = 2), or cotrimoxazole ( n  = 8). Thirteen conditions justifying not de-escalating antibacterial therapy were detected in 11 of 48 patients who were not de-escalated (23 %, 95 % CI, 12–37 %): shock, n  = 5; renal abscess, n  = 1; obstructive uropathy, n  = 4; bacterial resistance or clinical contraindication to both cotrimoxazole and β-lactams, n  = 3. Conclusions De-escalation is under-prescribed for urinary tract infections. Omission of de-escalation is seldom legitimate. Interventions aiming to de-escalate antibacterial therapy for UTIs should be actively implemented.