title: Why is antimicrobial de-escalation under-prescribed for urinary tract infections?
abstract: OBJECTIVE
  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.
authors.affiliation: Emergency Department, Nantes University Hospital, 1 Place Alexis-Ricordeau, 44000, Nantes, France.
authors.forename: E
authors.initials: E
authors.lastname: Duchêne
authors.forename: E
authors.initials: E
authors.lastname: Montassier
authors.forename: D
authors.initials: D
authors.lastname: Boutoille
authors.forename: J
authors.initials: J
authors.lastname: Caillon
authors.forename: G
authors.initials: G
authors.lastname: Potel
authors.forename: E
authors.initials: E
authors.lastname: Batard
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D017714:Community-Acquired Infections / Q000188:drug therapy; D005260:Female; D006801:Humans; D007297:Inpatients; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D016896:Treatment Outcome; D014552:Urinary Tract Infections / Q000188:drug therapy*; D055815:Young Adult
chemical_list: D000900:Anti-Bacterial Agents