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Delaying antibiotics in elderly with UTI linked to higher sepsis, death rates

Key clinical point: Delaying or withholding antibiotics in elderly patients with urinary tract infection may increase risk of sepsis and death.

Major finding: Bloodstream infection risk was more than seven times higher in patients not receiving immediate antibiotics versus those who did.

Study details: A population-based cohort study in the United Kingdom comprising 157,264 adult primary care patients at least 65 years of age with suspected or confirmed urinary tract infections.

Disclosures: This study was supported by the National Institute for Health Research and other U.K. sources. One study coauthor reported working as an epidemiologist with GSK in areas not related to the study.


Gharbi M et al. BMJ. 2019 Feb 27. doi: 10.1136/bmj.l525.


This study linking primary care prescribing to serious infections in elderly patients with urinary tract infections is timely, as rates of bloodstream infection and mortality are increasing in this age group, according to Alastair D. Hay, MB.ChB, a professor at University of Bristol, England.

“Prompt treatment should be offered to older patients, men (who are at higher risk than women), and those living in areas of greater socioeconomic deprivation who are at the highest risk of bloodstream infections,” Dr. Hay said in an editorial accompanying the report by Gharbi et al.

That said, the link between prescribing and infection in this particular study may not be causal: “The implications are likely to be more nuanced than primary care doctors risking the health of older adults to meet targets for antimicrobial stewardship,” Dr. Hay noted.

Doctors are cautious when managing infections in vulnerable groups, evidence shows, and the deferred prescribing reported in this study is likely not the same as the delayed prescribing seen in primary care, he explained.

“Most clinicians issue a prescription on the day of presentation, with verbal advice to delay treatment, rather than waiting for a patient to return or issuing a postdated prescription,” he said. “The group given immediate antibiotics in the study by Gharbi and colleagues likely contained some patients managed in this way.”

Patients who apparently had no prescription in this retrospective analysis may have had a same-day admission with a bloodstream infection; moreover, a number of bloodstream infections in older people are due to urinary tract bacteria, and so would not be prevented by treatment for urinary tract infection, Dr. Hay said.

“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,” he concluded.

Dr. Hay is a professor in the Centre for Academic Primary Care, University of Bristol, England. His editorial appears in The BMJ (2019 Feb 27. doi: 10.1136/bmj.l780). Dr. Hay declared that he is a member of the managing common infections guideline committee for the National Institute for Health and Care Excellence (NICE).