PROSPECTIVE COHORT STUDY OF ACUTE PYELONEPHRITIS IN ADULTS: SAFETY OF TRIAGE TOWARDS HOME BASED ORAL ANTIMICROBIAL TREATMENT C. VAN NIEUWKOOP A,*, J.W. VAN’T WOUT A,B, I.C. SPELT C, M. BECKER D, E.J. KUIJPER E, J.W. BLOM F, W.J.J. ASSENDELFT F, J.T. VAN DISSEL BRITISH INFECTION SOCIETY NOVEMBER 2009 R2 박 소영

Introduction  Acute pyelonephritis  Infection of the upper urinary tract that causes substantial morbidity, mortality and costs  In the last decades, hospitalization rates has decreased from almost 100% to 10~30%  Outpatient management has become popular  In current international guidelines,  Only upholds for non-pregnant previous healthy young to middle aged woman  Individuals with co-morbidity, the elderly and men with AP has not been addressed in any study.  Patients with AP and characteristics indicative or potential complications (e.g. male sex, old age, diamellitus, urinary tract abnormalities, frailty)  a low threshold for hospitalization

Introduction  Aim  Evaluate the outcome of elderly patients and those with co-morbidity managed at home  Patients treated at home with oral antibiotics by their general practitioners (GPs) were compared to patients referred to emergency departments

Patients and methods  Patients  with a presumptive diagnosis of community acquired AP  Inclusion criteria > 18 years old fever (38.2 C) history of fever and rigors including 24 hr before presentation, at least one symptom of upper and/or lower UTI and leukocyturia  Exclusion criteria current treatment for urolithiasis or hydronephrosis, known allergy to fluoroquinolones, pregnancy hemo- or peritoneal dialysis and a history of kidney transplantation or polycystic kidney disease

Patients and methods  Two group emergency department (ED) primary health care centres (PHC)  Methods  prospective observational multi-centre cohort study

Treatment  Treatment at home  10~14 day course of oral antibiotics : ciprofloxacin 500 mg b.i.d. (1st choice )  Treatment at hospital  empirical antibiotics intravenously : cefuroxim + gentamicin (1st choice)  based on the culture results, switched to oral antibiotic treatment (ciprofloxacin 500 mg b.i.d., 1st choice)  Referring a patient with suspected AP to hospital  in case of deteriorating sepsis, with presence of a likely urinary tract infection temperature >38 C or respiratory rate >20/min hemodynamic instability : sBP 110/min hypoperfusion: altered mental state, decreased urinary output, peripheral vasoconstriction

Results 486  : not meet the inclusion criteria 14 : refused participation 242 at EDs 35 (14%) treated as outpatients with oral ciprofloxacin 207 (86%) admitted and treated with cefuroxim + gentamicin iv 153 at PHCs 146 (95%) received oral ciprofloxacin

Microbiological data Uropathogens between PHC and ED was similar

Amoxicillin47% Amoxicillin-clavulanic acid10% Trimethoprim-sulfamethoxazol25% Ciprofloxacin9% Antibiotic-resistant E. coli The resistance patterns were similar between patients presenting at PHC or ED Blood cultures performed in 96% of cases bacteraemia in the PHC group : 10% bacteraemia in the ED group : 27%

Referral to hospital Eight (5%) of 153 PHC patients initially treated at home, were later referred to the hospital for additional treatment of acute pyelonephritis

Clinical outcome

Risk factors for complicated outcome and mortality

Discussion  This study is the first to provide evidence that patients with community acquired acute pyelonephritis and signs suggestive for complications can be safely treated with oral antibiotics at home  Using oral fluoroquinolones to treat acute pyelonephritis : acceptable rate of secondary admissions (5%) and a high clinical cure rate of 90%  Validity  The subjects reflect the daily clinical practice of patients presenting at community level of primary health care and emergency department  All patients were clinically and microbiologically well documented including the unique results of combined urine and blood cultures gathered at home  The data were collected prospectively and the broad inclusion criteria

Discussion  Limitation  Relative small sample size of patients  Selectively focused on patients with community acquired AP rather than health care associated UTIs the frequency of non-E. coli uropathogens or highly resistant uropathogens was relatively low  generalizing limitation  Fluoroquinolones or amoxicillin-clavulanic acid should be the preferred antibiotic for empirical oral treatment  Higher rate of ciprofloxacin-resistance than other studies  the higher rate of complicating features in our study our study population wasmuch older and suffered co-morbidity more frequently  The clinical cure rate of 90% of AP patients treated with oral ciprofloxacin  fluoroquinolones are more effective than b-lactam antibiotics in UTI  more frequently had history of UTIs

Discussion  The allocation of treatment is confounded by disease severity  Further studies are therefore needed in order to obtain a clinical prediction rule (or readily available bedside biomarker test) with higher specificity for severe urosepsis