Antibiotic Switches in Urinary Tract Infection Are Associated With Atypical Symptoms and Emergent Care

IMPORTANCE

Given worsening global antibiotic resistance, antimicrobial stewardship aims to use the shortest effective duration of the most narrow-spectrum, effective antibiotic for patients with specific urinary symptoms and laboratory testing consistent with urinary tract infection (UTI). Inappropriate treatment and unnecessary antibiotic switching for UTIs harms patients in a multitude of ways.

OBJECTIVE

This study sought to analyze antibiotic treatment failures as measured by antibiotic switching for treatment of UTI in emergent and ambulatory care.

STUDY DESIGN

For this retrospective cohort study, 908 encounters during July 2019 bearing a diagnostic code for UTI/cystitis in a single health care system were reviewed. Urinary and microbiological testing, symptoms endorsed at presentation, and treatments prescribed were extracted from the medical record.

RESULTS

Of 908 patients diagnosed with UTI, 64% of patients (579/908) received antibiotics, 86% of which were empiric. All patients evaluated in emergent care settings were prescribed antibiotics empirically in contrast to 71% of patients in ambulatory settings (P < 0.001). Of patients given antibiotics, 89 of 579 patients (15%, 10% of all 908 patients) were switched to alternative antibiotics within 28 days. Emergent care settings and positive urine cultures were significantly associated with increased antibiotic switching. Patients subjected to switching tended to have higher rates of presenting symptoms inconsistent with UTI.

CONCLUSIONS

Empiric treatment, particularly in an emergent care setting, was frequently inappropriate and associated with increasing rates of antibiotic switching. Given the profound potential contribution to antibiotic resistance, these findings highlight the need for improved diagnostic and prescribing accuracy for UTI.

Renal Endometriosis in a Postmenopausal Female Mimics Renal Cell Carcinoma

A 61-year-old postmenopausal female with a past medical history of type 2 diabetes, nephrolithiasis, and recurrent urinary tract infections presented to an outpatient urology clinic with a chief complaint of urinary frequency, urgency, and burning after micturition. Associated symptoms included nausea, a low-grade fever with chills, and right flank pain. After treatment with antibiotics did not relieve all of her symptoms, imaging was obtained, showing a cystic mass with calcifications in the right kidney. Following laparoscopic partial right nephrectomy and total hysterectomy with bilateral salpingo-oophorectomy, pathological examination of the right kidney mass highlighted endometrial stromal cells consistent with endometriosis of the right kidney. The left ovary also contained endometrial stromal cells, confirming another diagnosis of endometriosis of the left ovary. This case highlights the importance of considering renal endometriosis in the differential diagnosis of renal masses in women, even if they are postmenopausal.

Recurrent Urinary Tract Infection Incidence Rates Decrease in Women With Cystitis Cystica After Treatment With d-Mannose: A Cohort Study

OBJECTIVES

d-Mannose is a promising nonantibiotic prophylaxis for recurrent urinary tract infection (rUTI). Recurrent UTI is common in postmenopausal women and may be especially prevalent in those with cystitis cystica (CC) lesions found on cystoscopy. Our objectives were to determine whether CC lesions are associated with a higher UTI incidence rate and whether d-mannose reduces this rate in women with CC.

METHODS

This is a retrospective cohort study of patients with rUTI who underwent cystoscopy at our institution (from which CC status was identified) and who were treated with d-mannose as a single agent for UTI prophylaxis. Participants were required to have at least 1 year of follow-up for UTIs both before and after d-mannose initiation to allow for a pre-post comparison.

RESULTS

Twenty-seven patients were included in the analysis (13 with CC, 14 without CC). Most patients (88.9%) were postmenopausal. Patients with CC had a higher UTI incidence rate than patients without CC (4.69 vs 2.93 UTIs/year before starting d-mannose prophylaxis, P = 0.021). After initiating d-mannose prophylaxis, the UTI incidence rate decreased significantly in patients with CC (rate decrease = 2.23 UTIs/year, P = 0.0028). This decrease was similar in magnitude to that observed in patients without CC (rate decrease = 1.64 UTIs/year, P = 0.0007; P interaction = 0.58).

CONCLUSIONS

Patients with rUTI with CC had more frequent UTI episodes than patients without CC. Patients in both groups had fewer UTI episodes after beginning d-mannose prophylaxis. These findings add to the body of literature supporting d-mannose for the prevention of rUTI in women, including those with CC.