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Comparing outcomes among outpatients treated for pyelonephritis with oral cephalosporins versus first-line agents
Peter E Fosse1, Kevin M Brinkman2, Hannah M Brink2
1Department of Pharmacy, Brooke Army Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, TX, USA.
Abstract:
Fluoroquinolones and trimethoprim/sulfamethoxazole (TMP-SMX) are first-line agents for acute pyelonephritis. Oral β-lactams are second-line agents owing to reported lower efficacy rates, primarily seen with aminopenicillins rather than cephalosporins. The increase in resistance rates and adverse effects associated with first-line agents provides justification to reconsider oral cephalosporins for pyelonephritis. Therefore, the objective of this study was to determine whether there is a difference in urinary tract infection (UTI) recurrence rates between oral cephalosporins and first-line agents in the treatment of acute pyelonephritis. This was a retrospective, single-centre, observational cohort study from 1 December 2018 to 31 May 2020. The study population was adult TRICARE beneficiaries with a diagnosis of acute pyelonephritis who were treated with oral antibiotics. The two cohorts compared were first-line antibiotics (ciprofloxacin, levofloxacin and TMP-SMX) and oral cephalosporins. The primary outcome was UTI recurrence rate at 30 days, which was defined as a repeat clinic visit, emergency department visit or hospital admission for a UTI (cystitis or pyelonephritis). The secondary outcome was to determine independent risk factors for UTI recurrence. A total of 268 cephalosporin and 211 first-line cases were included. The primary composite outcome of UTI recurrence within 30 days occurred in 44 (16%) cephalosporin and 36 (17%) first-line cases (P = 0.851). Independent risk factors for UTI recurrence were chronic kidney disease and Klebsiella spp. isolation. In conclusion, there was no significant difference in UTI recurrence rates between oral cephalosporins and first-line agents in the treatment of acute pyelonephritis in the outpatient setting.
Insights
Oral cephalosporins show similar urinary tract infection (UTI) recurrence rates to first-line agents for acute pyelonephritis. This study compared cephalosporins against fluoroquinolones and trimethoprim/sulfamethoxazole (TMP-SMX) in adult patients.
Area of Science:
- Infectious Diseases
- Pharmacology
- Urology
Background:
- Fluoroquinolones and trimethoprim/sulfamethoxazole (TMP-SMX) are standard first-line treatments for acute pyelonephritis.
- Oral beta-lactams, including cephalosporins, are considered second-line due to historically lower efficacy.
- Rising resistance and adverse effects of first-line agents necessitate evaluating alternative treatments like oral cephalosporins.
Purpose of the Study:
- To compare the 30-day urinary tract infection (UTI) recurrence rates between oral cephalosporins and first-line agents (fluoroquinolones, TMP-SMX) for acute pyelonephritis.
- To identify independent risk factors associated with UTI recurrence after treatment for acute pyelonephritis.
Main Methods:
- Retrospective, single-center, observational cohort study.
- Inclusion of adult TRICARE beneficiaries diagnosed with acute pyelonephritis treated with oral antibiotics from December 2018 to May 2020.
- Comparison of UTI recurrence rates between cohorts receiving oral cephalosporins versus first-line agents (ciprofloxacin, levofloxacin, TMP-SMX).
Main Results:
- A total of 268 patients received oral cephalosporins and 211 received first-line agents.
- The 30-day UTI recurrence rate was 16% (44/268) for cephalosporins and 17% (36/211) for first-line agents (P=0.851).
- Chronic kidney disease and isolation of Klebsiella spp. were identified as independent risk factors for UTI recurrence.
Conclusions:
- No significant difference in 30-day UTI recurrence rates was observed between oral cephalosporins and first-line agents for outpatient treatment of acute pyelonephritis.
- Oral cephalosporins represent a viable alternative treatment option for acute pyelonephritis, particularly given concerns about first-line agent resistance and side effects.
- Further research may explore specific cephalosporin efficacy and patient subgroups who might benefit most.
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