Antibiotic de-escalation in bacteremic urinary tract infections: potential opportunities and effect on outcome

The aim of this study was to examine the safety and efficacy of antibiotic de-escalation in patients admitted with bacteremic urinary tract infection (UTI). A retrospective chart review of patients admitted to a community-hospital in West Texas with bacteremic UTI during the year 2008. Antibiotic de-escalation was defined as changing the intravenous empiric antibiotic regimen to a culture-directed single agent, given intravenously or orally, with a narrower spectrum than the original empiric regimen. Ninety-seven patients were admitted with bacteremic UTI. Thirty-two patients were not eligible for de-escalation. Among the 65 patients who were eligible for de-escalation, the treating physicians failed to de-escalate antibiotics in 31 cases (47.7 %). Fluoroquinolones' resistance, bacteria other than Escherichia coli and discharge to long-term care facilities predicted failure to de-escalate antibiotics. On multivariate analysis, discharge to long-term care facility was the only risk factor that predicted failure to de-escalate antibiotics. The difference between mean hospital length of stay and mortality between the above two groups was not statistically significant. Antibiotic de-escalation is under-recognized and sporadically practiced. In patients admitted with bacteremic UTI, empiric antibiotic regimen can be changed to a culture-directed single antibiotic without an increase in hospital length of stay or patients' mortality.