Why is antimicrobial de-escalation under-prescribed for urinary tract infections?

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.

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.

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.

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.