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Risk of adverse outcomes following urinary tract infection in older people with renal impairment: retrospective cohort study using linked health record data

Ahmed, Haroon, Farewell, Daniel, Francis, Nicholas, Paranjothy, Shantini and Butler, Christopher 2018. Risk of adverse outcomes following urinary tract infection in older people with renal impairment: retrospective cohort study using linked health record data. PLoS Medicine 15 (9) , e1002652. 10.1371/journal.pmed.1002652

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Abstract

Background Few studies have investigated the risk of adverse outcomes in older people with renal impairment presenting to primary care with a urinary tract infection (UTI). The aim of this study was to determine the risk of adverse outcomes in patients aged ≥65 years presenting to primary care with a UTI, by estimated glomerular filtration rate (eGFR) and empirical prescription of nitrofurantoin versus trimethoprim. Methods and Findings This was a retrospective cohort study using linked health record data from 795,484 patients from 393 general practices in England, who were aged ≥65 years between 2010 and 2016. Patients were entered into the cohort if they presented with a UTI and had a creatinine measurement in the 24 months prior to presentation. We calculated an eGFR to estimate risk of adverse outcomes by renal function, and propensity-score matched patients with eGFRs <60mls/min/1.73m2 to estimate risk of adverse outcomes between those prescribed trimethoprim and nitrofurantoin. Outcomes were 14-day risk of re-consultation for urinary symptoms and same-day antibiotic prescription (proxy for treatment non-response), hospitalisation for UTI, sepsis, or acute kidney injury (AKI), and 28-day risk of death. Of 123,607 eligible patients with a UTI, we calculated an eGFR for 116,945 (95%). Median age was 76 (IQR, 70-83) years and 32,428 (28%) were male. Compared to an eGFR of >60mls/min/1.73m2, patients with an eGFR of <60mls/min/1.73m2 had greater odds of hospitalisation for UTI (adjusted ORs ranged from 1.14, (95% CI 1.01-1.28, p=0.028) for eGFRs of 45-59, to 1.68 (95% CI 1.01-2.82, p<0.001) for eGFRs<15), and AKI (adjusted ORs ranged from 1.57, (95% CI 1.29-1.91, p<0.001) for eGFRs of 45-59, to 4.53 (95% CI 2.52-8.17, p<0.001) for eGFRs<15). Compared to an eGFR of >60mls/min/1.73m2, patients with an eGFR of <45 had significantly greater odds of hospitalisation for sepsis, and those with an eGFR <30 had significantly greater odds of death. Compared to trimethoprim, nitrofurantoin prescribing was associated with lower odds of hospitalisation for AKI (ORs ranged from 0.62, (95% CI 0.40-0.94, p=0.025) for eGFRs of 45-59 to 0.45 (95% CI 0.25-0.81, p=0.008) for eGFRs <30). Nitrofurantoin was not associated with greater odds of any adverse outcome. Our study lacked data on urine microbiology and antibiotic-related adverse events. Despite our design, residual confounding may still have affected some of our findings. Conclusions Older patients with renal impairment presenting to primary care with a UTI had an increased risk of UTI-related hospitalisation and death, suggesting a need for interventions that reduce the risk of these adverse outcomes. Nitrofurantoin prescribing was not associated with an increased risk of adverse outcomes in patients with an eGFR <60mls/min/1.73m2 and could be used more widely in this population.

Item Type: Article
Date Type: Publication
Status: Published
Schools: Medicine
Publisher: Public Library of Science
ISSN: 1549-1277
Funders: NIHR/HCRW
Date of First Compliant Deposit: 13 August 2018
Date of Acceptance: 13 August 2018
Last Modified: 22 Apr 2019 19:35
URI: http://orca.cf.ac.uk/id/eprint/114159

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