Risk of adverse outcomes following urinary tract infection in older people with renal impairment: Retrospective cohort study using linked health record data.
Risk of adverse outcomes following urinary tract infection in older people with renal impairment: Retrospective cohort study using linked health record data.
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DOI：
10.1371/journal.pmed.1002652
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发表时间：
2018-09
期刊：
影响因子：
15.8
通讯作者：
Butler CC
中科院分区：
文献类型：
--
作者：
Ahmed H;Farewell D;Francis NA;Paranjothy S;Butler CC
很少有研究调查了因尿路感染（UTI）就诊的老年肾功能损害患者的不良结局风险。本研究的目的是通过估计肾小球滤过率（eGFR）和硝基呋喃妥因与甲氧苄啶的经验处方，确定年龄≥65岁的UTI初级保健患者的不良结局风险。这是一项回顾性队列研究，使用了英格兰393家全科诊所795,484名患者的相关健康记录数据，这些患者在2010年至2016年期间年龄≥65岁。如果患者出现尿路感染，并在出现尿路感染前24个月内进行肌酐测量，则进入队列。我们计算了eGFR，通过肾功能来估计不良结局的风险，并对eGFR <60 mL/min /1.73 m2的患者进行倾向评分匹配，以估计甲氧苄啶和呋喃妥因处方之间的不良结局风险。结果为14天内因泌尿系统症状再次就诊的风险和当天的抗生素处方（替代治疗无效），因尿路感染、败血症或急性肾损伤（AKI）住院的风险，以及28天内死亡的风险。在123,607例符合条件的UTI患者中，我们计算了116,945例（95%）的eGFR。中位年龄为76岁（IQR， 70-83岁），男性32,428例（28%）。相比的eGFR > 60毫升/分钟/ 1.73平方米,患者的eGFR < 60毫升/分钟/ 1.73平方米为泌尿道感染住院的几率较高(调整后的优势比(ORs)范围从1.14(95%可信区间(CI) 1.01 - -1.28, p = 0.028),举个45-59,1.68 (95% CI 1.01 - -2.82, p < 0.001] eGFRs < 15)和阿基(调整口服补液盐范围从1.57 (95% CI 1.29 - -1.91, p < 0.001),举个45-59,为4.53 (95% CI 2.52 - -8.17, p < 0.001),举个< 15)。与eGFR为60 mL/min /1.73 m2的患者相比，eGFR <45的患者因败血症住院的几率显著增加，而eGFR <30的患者死亡几率显著增加。与甲氧苄氨嘧啶相比，呋喃妥因处方与AKI住院的几率较低相关（or范围从egfr为45-59的0.62 [95% CI 0.40-0.94, p = 0.025]到egfr <30的0.45 [95% CI 0.25-0.81, p = 0.008]）。呋喃妥因与任何不良后果的发生率无关。我们的研究缺乏尿液微生物学和抗生素相关不良事件的数据。尽管我们的设计，残留混淆可能仍然影响了我们的一些发现。因尿路感染就诊的老年肾功能损害患者与尿路相关的住院和死亡风险增加，这表明需要采取干预措施来降低这些不良后果的风险。在eGFR <60 mL/min /1.73 m2的患者中，呋喃妥因处方与不良结局风险增加无关，可以在这一人群中更广泛地使用。在这项回顾性研究中，Haroon Ahmed及其同事调查了老年人常见尿路感染和肾功能受损之间的相关风险，以及与呋喃妥因处方相关的结果。目前尚不清楚肾功能受损的老年人在尿路感染（UTI）后住院或死亡的风险是否增加。呋喃妥因是一种用于治疗尿路感染的抗生素，但不建议肾功能受损的人使用。然而，支持这一建议的证据有限。本研究使用了来自英格兰全科诊所和医院的相关健康记录数据，并估计了因疑似尿路感染而就诊的肾功能受损老年人的住院和死亡风险。肾功能受损的老年人在尿路感染后14-28天内与尿路相关的住院和死亡的风险更高。用呋喃妥因治疗肾功能受损的老年人发生不良后果的风险不高，因肾功能恶化而住院的可能性也较小。有必要制定预防尿路感染和降低肾功能受损老年人尿路相关住院和死亡风险的策略。呋喃妥因与较差的预后无关，可以在这一人群中更广泛地使用。
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. 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 <60 mL/minute/1.73 m2 to estimate risk of adverse outcomes between those prescribed trimethoprim and nitrofurantoin. Outcomes were 14-day risk of reconsultation for urinary symptoms and same-day antibiotic prescription (proxy for treatment nonresponse), 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 >60 mL/minute/1.73 m2, patients with an eGFR of <60 mL/minute/1.73 m2 had greater odds of hospitalisation for UTI (adjusted odds ratios [ORs] ranged from 1.14 [95% confidence interval (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 >60 mL/minute/1.73 m2, patients with an eGFR <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. 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 <60 mL/minute/1.73 m2 and could be used more widely in this population. In this retrospective study, Haroon Ahmed and colleagues investigate associated risks between common urinary tract infection and impaired kidney function in older adults, as well as outcomes related to nitrofurantoin prescription. It is not known if older adults with impaired kidney function are at increased risk of hospitalisation or death following a urinary tract infection (UTI). Nitrofurantoin is an antibiotic used to treat UTI but is not recommended in people with impaired kidney function. However, the evidence supporting this recommendation is limited. This study used linked health record data from general practices and hospitals in England and estimated risk of hospitalisation and death for older adults with impaired kidney function presenting to primary care with a suspected UTI. Older adults with impaired kidney function had greater risk of a UTI-related hospitalisation and death in the 14–28 days following a UTI. Older adults with impaired kidney function who were treated with nitrofurantoin were not at greater risk of an adverse outcome and were less likely to experience a hospital admission for worsening kidney function. There is a need for strategies that prevent UTIs and reduce the risk of UTI-related hospitalisations and death in older adults with impaired kidney function. Nitrofurantoin was not associated with worse outcomes and could be used more widely in this population.
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通讯作者：
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