Harms of UTI prophylaxis outweigh benefits in older adults
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Older adult patients who received antibiotic prophylaxis for UTIs experienced an increased risk for hospitalization, sepsis and bloodstream infection, according to a study in Clinical Infectious Diseases.
“Older patients have a higher risk of infection than younger patients due in large part to immunosenescence, but at the same time they are more prone to the harms of antibiotics such as adverse events, drug-drug interactions and Clostridioides difficile infections. So, assessing both the risks and benefits of antibiotics is particularly important in this population,” Bradley J. Langford, PharmD, a pharmacist consultant at Public Health Ontario, told Healio.
“We know that UTIs are one of the most common infections leading to hospitalization, and recurrent UTIs are particularly burdensome, so a common strategy employed is the use of long-term antibiotic prophylaxis,” Langford said. “Although in many studies UTI prophylaxis is associated with a reduced risk of recurrent UTI, this benefit is less certain in older adults. So, we wanted to find out if we could better understand the risks and benefits of UTI prophylaxis in this population.”
Langford and colleagues conducted a matched cohort study comparing 3,190 older adults aged 66 years and older who were receiving antibiotic prophylaxis to patients with positive urine cultures who received antibiotic treatment but did not receive prophylaxis. Outcomes included an ED visit or hospitalization for UTI, sepsis or bloodstream infection within 1 year, acquisition of antibiotic resistance in urinary tract pathogens and antibiotic-related complications.
Overall, antibiotic prophylaxis was associated with a 1.3-fold increase in the risk of hospitalization or ED visit for UTI, sepsis and/or bloodstream infection — 4.7% of patients who received UTI 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).
Additionally, 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) were higher in patients receiving prophylaxis. The researchers noted that although the overall risk of antibiotic-related complications was similar between groups (HR = 1.08; 95% CI, 0.94-1.22), the risk for C. difficile and general medication adverse events was higher in prophylaxis recipients (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 could be due to underlying differences between patients receiving prophylaxis and those who are not. However, he said the potential impact antibiotics have on the protective flora is a “more intriguing” explanation.
“It is possible that because antibiotic prophylaxis disrupts local gastrointestinal and vaginal flora, it may predispose patients to colonization with more pathogenic and/or more resistant strains of organisms,” he said.
“We hope that this study encourages clinicians to be more cognizant of potential harms of UTI antibiotic prophylaxis when deciding on treatment and discussing both the risks and benefits with patients and their families,” Langford said. “As shown in our study and other previous studies evaluating UTI prophylaxis, prolonged antibiotic use selects for antimicrobial resistant organisms, which can make subsequent symptomatic episodes more difficult to treat and as such can lead to worse patient outcomes.”
Despite this, Langford said there may still be a role for UTI prophylaxis in older adults, especially those with frequent symptomatic UTIs and those with severe symptoms, “but the findings of our study may help to prompt clinicians to consider other measures (eg, vaginal estrogens, acute on-demand treatment) before escalating to long-term prophylaxis.”
Perspective
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Despite evidence that antibiotic prophylaxis may be beneficial in patients with recurrent UTIs, potential harms and adverse events related to prophylaxis have not been investigated, especially in older adults. Older adults, with a high incidence of asymptomatic bacteriuria, are at risk for inappropriate antibiotic treatment, followed by unnecessary antibiotic prophylaxis. A recent article in Clinical Infectious Diseases investigated the benefits and harms of antibiotic prophylaxis for older adults with a history of positive urine cultures.
This retrospective cohort study compared outcomes in matched older adults (≥ 66 years) with positive urine cultures who did and did not receive antibiotic prophylaxis. The authors found no detectable clinical benefit of antibiotic prophylaxis, and prophylaxis was associated with an increased risk of ED visit or hospitalization for UTI, sepsis or bloodstream infection. Antibiotic prophylaxis was also associated with an increased risk of antibiotic-related harms, specifically antibiotic resistance. This study highlights the need to critically assess if older patients need antibiotic prophylaxis for presumed UTIs because the risks may outweigh benefits.
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