1. 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

2. 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

3. 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

4. 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

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

6. 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

7. Results 486  395 77 : 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

9. Microbiological data Uropathogens between PHC and ED was similar

10. 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%

11. 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

12. Clinical outcome

13. Risk factors for complicated outcome and mortality

14. 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

15. 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

16. 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