Prospective cohort study of acute pyelonephritis in adults: Safety of triage towards home based oral antimicrobial treatment

• Published in: The Journal of infection Vol. 60; no. 2; pp. 114 - 121
• Main Authors: van Nieuwkoop, C, van't Wout, J.W, Spelt, I.C, Becker, M, Kuijper, E.J, Blom, J.W, Assendelft, W.J.J, van Dissel, J.T
• Format: Journal Article
• Language: English
• Published: Amsterdam Elsevier Ltd 01.02.2010; Elsevier
• Subjects: Acute pyelonephritis; Administration, Oral; Adult; Aged; Anti-Bacterial Agents - administration & dosage; Anti-Bacterial Agents - therapeutic use; Bacterial diseases; Bacterial diseases of the urinary system; Biological and medical sciences; Cohort Studies; Complicated UTI; Female; General aspects; Health Services Research; Home based treatment; Home Care Services - statistics & numerical data; Human bacterial diseases; Humans; Infectious Disease; Infectious diseases; Interstitial nephritis; Male; Medical sciences; Middle Aged; Nephrology. Urinary tract diseases; Nephropathies. Renovascular diseases. Renal failure; Primary care; Prospective Studies; Pyelonephritis - drug therapy; Treatment Outcome; Urinary tract infection; Complicated UTI; Urinary tract infection; Home based treatment; Primary care; Acute pyelonephritis; Human; Kidney disease; Infection; Urinary system disease; Treatment; Acute; Cohort study; Pyelonephritis; Oral administration; Adult; Antimicrobial agent; Ascending pyelonephritis
• ISSN: 0163-4453; 1532-2742
• DOI: 10.1016/j.jinf.2009.11.008

Summary Objective Home-based treatment of acute pyelonephritis (AP) is generally reserved for young non-pregnant women who lack co-morbidity. This study, focusing on the elderly and patients with co-morbidity, evaluates the Dutch primary care guideline that recommends referral to hospital only in case of suspected deterioration to severe sepsis or failure of antibiotic treatment, irrespective of patient's age, sex or co-morbidity. Methods A prospective observational cohort study including consecutive non-pregnant adults with AP. Clinical and microbiological outcome measures of non-referred patients from 35 primary health care centres (PHC) were compared to patients referred to two affiliating emergency departments (EDs). Results Of 395 evaluable patients, 153 were treated by PHCs and 242 referred to EDs. The median age was 63 years [IQR 43–77], 34% were male, 58% had co-morbidity; all comparable between the PHC and ED group. Referred ED patients were more likely to have signs of sepsis and to have been pre-treated with antibiotics. Bacteraemia was present in 10% of patients in the PHC group and 27% in the ED group (RR 2.83; 95% CI: 1.64–4.86, p < 0.001). Eight (5%) PHC patients were admitted during outpatient treatment but otherwise no major complications occurred. Clinical failure rates at 30 days were similar between PHC patients and ED patients; 9% and 10% respectively. Mortality rates of PHC patients versus ED patients were 1% versus 5% at 30 days ( p = 0.058) and 1% versus 7% at 90 days ( p = 0.007). Complicated outcome occurred in 6% of the PHC patients versus 12% in the patients referred to ED ( p = 0.067). Conclusion In a health care system with a well-organized primary care system and clear guideline, the outcome of adults with acute pyelonephritis, including men, the elderly and patients with co-morbidity, selected for oral antibiotic treatment at home did not lead to major complications.