When Does Empirical Treatment Fail for Uncomplicated UTIs?

[Argirios Argiriou]

Journal Watch, April 15, 2025

When Does Empirical Treatment Fail for Uncomplicated UTIs?

Abigail Zuger, MD, reviewing Fromer DL et al. J Gen Intern Med 2025 Mar

Be worried about patients in whom treatment has failed previously.

Urinary tract infections (UTIs) in women are easily treated … except when they aren't. Empirical antibiotics fail more often than we would like, leading to ongoing discomfort, increased cost, and more antibiotic use. Using data for 2017 to 2021 that were extracted from a nationwide electronic health record, industry-supported researchers tallied treatment outcomes among more than 370,000 U.S. women who received empirical oral antibiotics for uncomplicated UTIs.

The overall rate of treatment failure (defined as the need for an additional antibiotic prescription) was 17%. Failure rates were considerably higher among those with previous UTI treatment failures (34%). High rates of failure were also seen among patients who had received ≥3 oral antibiotic prescriptions for any indication in the previous year (25%), among those seeking care in emergency or urgent care settings (21%–22%), and among those 75 or older (21%).

Obesity and diabetes both were associated with slightly higher failure rates. The few hundred patients who received fosfomycin had a higher failure rate (30%) than those given other antibiotics.

Comment

These data come with the gigantic caveat that, because no clinical data were analyzed, “treatment failure” for a UTI might indicate that a UTI actually was never present, and the patient was suffering from another pelvic problem. For patients with confirmed UTIs, can the data be distilled into a helpful management suggestion? I would vote for this one: When patients have previous treatment failures, heavy recent antibiotic use, or are 75 and older, let's just ignore standard protocols and order pretreatment cultures. This practice might not protect against treatment failure but knowing the pathogen sooner rather than later undoubtedly will help us prevent some of the fallout.

Citations

Fromer DL et al. Risk factors for empiric treatment failure in US female outpatients with uncomplicated urinary tract infection: An observational study. J Gen Intern Med 2025 Mar; 40:862. (Δεν είναι ορατοί οι σύνδεσμοι (links). Εγγραφή ή Είσοδος)