title: Two Simple Rules for Improving the Accuracy of Empiric Treatment of Multidrug-Resistant Urinary Tract Infections.
abstract: The emergence of multidrug-resistant (MDR) uropathogens is making the treatment of urinary tract infections (UTIs) more challenging. We sought to evaluate the accuracy of empiric therapy for MDR UTIs and the utility of prior culture data in improving the accuracy of the therapy chosen. The electronic health records from three U.S. Department of Veterans Affairs facilities were retrospectively reviewed for the treatments used for MDR UTIs over 4 years. An MDR UTI was defined as an infection caused by a uropathogen resistant to three or more classes of drugs and identified by a clinician to require therapy. Previous data on culture results, antimicrobial use, and outcomes were captured from records from inpatient and outpatient settings. Among 126 patient episodes of MDR UTIs, the choices of empiric therapy against the index pathogen were accurate in 66 (52%) episodes. For the 95 patient episodes for which prior microbiologic data were available, when empiric therapy was concordant with the prior microbiologic data, the rate of accuracy of the treatment against the uropathogen improved from 32% to 76% (odds ratio, 6.9; 95% confidence interval, 2.7 to 17.1; P < 0.001). Genitourinary tract (GU)-directed agents (nitrofurantoin or sulfa agents) were equally as likely as broad-spectrum agents to be accurate (P = 0.3). Choosing an agent concordant with previous microbiologic data significantly increased the chance of accuracy of therapy for MDR UTIs, even if the previous uropathogen was a different species. Also, GU-directed or broad-spectrum therapy choices were equally likely to be accurate. The accuracy of empiric therapy could be improved by the use of these simple rules.
authors.affiliation: VA Boston Healthcare System, Boston, Massachusetts, USA Boston University School of Medicine, Boston, Massachusetts, USA Katherine.Linsenmeyer@bmc.org.
authors.forename: Katherine
authors.initials: K
authors.lastname: Linsenmeyer
authors.affiliation: VA Boston Healthcare System, Boston, Massachusetts, USA Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Judith
authors.initials: J
authors.lastname: Strymish
authors.affiliation: VA Boston Healthcare System, Boston, Massachusetts, USA Boston University School of Medicine, Boston, Massachusetts, USA VA National Center for Occupational Health and Infection Control, Gainesville, Florida, USA.
authors.forename: Kalpana
authors.initials: K
authors.lastname: Gupta
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D016208:Databases, Factual; D024901:Drug Resistance, Multiple, Bacterial; D036262:Empirical Research; D006801:Humans; D008826:Microbial Sensitivity Tests; D009582:Nitrofurantoin / Q000627:therapeutic use*; D013424:Sulfanilamides / Q000627:therapeutic use*; D016896:Treatment Outcome; D014481:United States; D014493:United States Department of Veterans Affairs; D014551:Urinary Tract / Q000187:drug effects* / Q000382:microbiology / Q000503:physiopathology; D014552:Urinary Tract Infections / Q000175:diagnosis / Q000188:drug therapy* / Q000382:microbiology / Q000503:physiopathology
chemical_list: D000900:Anti-Bacterial Agents; D013424:Sulfanilamides; D009582:Nitrofurantoin